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Walcutt JE, Kline-Fath BM, Zhang B, Lim FY, Habli MA, Divanovic AA, Nagaraj UD. Fetal magnetic resonance imaging, ultrasound, and echocardiography findings in twin reversed arterial perfusion sequence. Pediatr Radiol 2024; 54:702-714. [PMID: 38488924 DOI: 10.1007/s00247-024-05879-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/03/2024] [Accepted: 02/06/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Twin reversed arterial perfusion (TRAP) sequence is a rare complication of monochorionic multiple gestation pregnancies, in which the pump twin provides hemodynamic support to a nonviable co-twin (acardius). Fetal magnetic resonance imaging (MRI) is used to detect pump twin abnormalities, particularly brain ischemia, prior to fetal intervention to interrupt umbilical blood flow to the acardius. OBJECTIVE To summarize the imaging findings of TRAP sequence pregnancies in a large series. MATERIALS AND METHODS A single-center retrospective review was performed of all TRAP sequence pregnancies referred for fetal MRI (2004-2021). Fetal MRI, ultrasound, and echocardiography data were collected. RESULTS Eighty-eight TRAP sequence pregnancies with MRI were included (mean gestational age, 19.8±2.8 weeks). Demise of the pump twin was noted in two pregnancies at the time of MRI. By MRI, 12% (10/86) of live pump twins had abnormalities, including 3% (3/86) with brain abnormalities and 9% (8/86) with extra-cranial abnormalities. By echocardiography, 7% (6/86) of pump twins had structural cardiac abnormalities. Three acardius morphological subtypes were identified by MRI: acephalus (55%, 48/88), anceps (39%, 34/88), and amorphous (7%, 6/88). The mean ultrasound acardius to pump twin ratio A/P ratio, calculated for each twin pair as the ratio of the acardius trunk (and head, if present) plus limb volume to the pump twin estimated fetal weight) differed among the three acardius subtypes (P=.03). The mean A/P ratio moderately correlated with pump twin cardiothoracic ratio and combined cardiac output (Pearson's r=0.45 and 0.48, respectively, both P<.001). CONCLUSION Fetal MRI of TRAP sequence pregnancies found anomalies in a substantial number of pump twins. The three acardius subtypes differed in A/P ratio, which moderately correlated with the pump twin cardiothoracic ratio and combined cardiac output.
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Affiliation(s)
- Julie E Walcutt
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.
- Division of Radiology, Children's Nebraska, 8200 Dodge Street, Omaha, NE, 68114, USA.
- Department of Radiology, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Beth M Kline-Fath
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Foong-Yen Lim
- Department of Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mounira A Habli
- Department of Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Obstetrics and Gynecology, TriHealth Good Samaritan Hospital, Cincinnati, OH, USA
| | - Allison A Divanovic
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Usha D Nagaraj
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Zhang YH, Jiao'e P, Chen L, Zhou WX, Zhan H, Chen LQ, Lin J, Wen H. New radiofrequency ablation procedure for selective reduction in complicated monochorionic twin or triplet pregnancy using multistep, incremental expansion technique. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:522-528. [PMID: 37767731 DOI: 10.1002/uog.27508] [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: 05/23/2023] [Revised: 09/09/2023] [Accepted: 09/20/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVE Radiofrequency ablation (RFA) is the preferred approach for selective reduction in complex monochorionic (MC) multiple pregnancies owing to the ease of operation and minimal invasiveness. To optimize the RFA technique and reduce the risk of adverse pregnancy outcome resulting from the heat-sink effect of RFA therapy, we used an innovative RFA method, in which an electrode needle was expanded incrementally and stepwise. This study aimed to assess the efficacy and safety profile of this novel multistep incremental expansion RFA method for selective fetal reduction in MC twin and triplet pregnancies. METHODS This was a single-center retrospective cohort study of all MC multiple pregnancies undergoing RFA between March 2016 and October 2022 at our center. The multistep RFA technique involved the use of an expandable needle, which was gradually expanded during the RFA procedure until cessation of umbilical cord blood flow was achieved. The needle used for the single-step RFA method was fully extended from the start of treatment. RESULTS In total, 132 MC multiple pregnancies underwent selective reduction using RFA, including 50 cases undergoing multistep RFA and 82 cases undergoing single-step RFA. The overall survival rates were not significantly different between the multistep and single-step RFA groups (81.1% vs 72.3%; P = 0.234). Similarly, the rates of preterm prelabor rupture of the membranes within 2 weeks after RFA, procedure-related complications, spontaneous preterm delivery and pathological findings on cranial ultrasound, as well as gestational age at delivery and birth weight, did not differ between the two groups. However, there was a trend towards a prolonged procedure-to-delivery interval following multistep RFA compared with single-step RFA (median, 109 vs 99 days; P = 0.377). Moreover, the fetal loss rate within 2 weeks after RFA in the multistep RFA group was significantly lower than that in the single-step RFA group (10.0% vs 24.4%; P = 0.041). The median ablation time was shorter (5.3 vs 7.8 min; P < 0.001) and the median ablation energy was lower (10.2 vs 18.0 kJ; P < 0.001) in multistep compared with single-step RFA. There were no significant differences in neonatal outcomes following multistep vs single-step RFA. CONCLUSIONS Overall survival rates were similar between the two RFA methods. However, the multistep RFA technique was associated with a lower risk of fetal loss within 2 weeks after RFA. The multistep RFA technique required significantly less ablation energy and a shorter ablation time compared with single-step RFA in selective fetal reduction of MC twin and triplet pregnancies. Additionally, there was a trend towards a prolonged procedure-to-delivery interval with the multistep RFA technique. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- Y-H Zhang
- Zhejiang University School of Medicine, Women's Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - P Jiao'e
- Zhejiang University School of Medicine, Women's Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - L Chen
- Zhejiang University School of Medicine, Women's Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - W-X Zhou
- Zhejiang University School of Medicine, Women's Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - H Zhan
- Zhejiang University School of Medicine, Women's Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - L-Q Chen
- Zhejiang University School of Medicine, Women's Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - J Lin
- Zhejiang University School of Medicine, Women's Hospital, Hangzhou, Zhejiang, People's Republic of China
| | - H Wen
- Zhejiang University School of Medicine, Women's Hospital, Hangzhou, Zhejiang, People's Republic of China
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Ventura W, Sugajara R, Quintana W, Llancarí P, Novoa RH. A systematic review of early intrauterine intervention at 12 + 0 to 16 + 6 weeks in twin reversed arterial perfusion sequence. Eur J Obstet Gynecol Reprod Biol 2024; 295:92-97. [PMID: 38342009 DOI: 10.1016/j.ejogrb.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 01/08/2024] [Accepted: 02/01/2024] [Indexed: 02/13/2024]
Abstract
There is some evidence that in twin reversed arterial perfusion sequence, intervention at early gestational age could prevent a spontaneous death of the pump twin, achieving a better global survival. OBJECTIVE To review the perinatal outcomes of early intervention in pregnancies complicated by twin reversed arterial perfusion (TRAP) sequence. STUDY DESIGN A comprehensive search from inception to December 2022 was conducted on databases including MEDLINE, EMBASE, Cochrane Library and LILACS. All studies that reported intervention in twin or triplet pregnancy complicated with TRAP sequence at 12 + 0 to 16 + 6 weeks of gestation were eligible. A descriptive and bivariate analysis was performed. RESULTS Out of the 222 full-text articles, 44 studies reporting 108 cases of early intervention in TRAP sequence were included. A successful procedure was achieved in 105 (95.5 %) interventions: 89 (94.7 %) among twin pregnancies and 16(100 %) among triplet pregnancies. An overall livebirth rate was achieved in 75 patients (70.8 %): intrafetal laser group 55 (73.3 %), radiofrequency 10 (76.9 %) and endoscopic laser 3 (75.0 %). The median gestational age at delivery was 38 + 0 (37 + 4 - 39 + 4) weeks. The median treatment-delivery interval was 23 + 2 (IQR, 21 + 0-25 + 6) weeks. The most frequent adverse outcomes reported were preterm labor in 7 (13.7 %) patients. There were no severe adverse maternal outcomes. CONCLUSION Early intervention with intrafetal laser and radiofrequency in TRAP sequence achieves a livebirth rate of the pump twin of about 75 %.
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Affiliation(s)
- Walter Ventura
- Fetal Medicine Unit, Department of Obstetrics and Perinatology, Instituto Nacional Materno Perinatal, Lima, Peru; Medicina Fetal Peru & Fetal Medicine Unit at Clínica Internacional and Clinica Anglo Americana, Lima, Peru.
| | - Ricardo Sugajara
- Fetal Medicine Unit, Department of Obstetrics and Perinatology, Instituto Nacional Materno Perinatal, Lima, Peru
| | - Willy Quintana
- High-Risk Pregnancy Unit, Department of Obstetrics and Perinatology, Instituto Nacional Materno Perinatal, Lima, Peru
| | - Pedro Llancarí
- Emergency Department, Instituto Nacional Materno Perinatal, Lima, Peru
| | - Rommy H Novoa
- High-Risk Pregnancy Unit, Department of Obstetrics and Perinatology, Instituto Nacional Materno Perinatal, Lima, Peru
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Walasik I, Litwinska M, Janiak K, Szaflik K, Kaczmarek P, Ludwin A, Litwinska E. Outcome of Monochorionic Diamniotic Twins with Twin Reversed Arterial Perfusion Sequence: Interstitial Laser versus Endoscopic Cord Occlusion. J Clin Med 2023; 12:6593. [PMID: 37892732 PMCID: PMC10607863 DOI: 10.3390/jcm12206593] [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: 08/06/2023] [Revised: 09/28/2023] [Accepted: 10/03/2023] [Indexed: 10/29/2023] Open
Abstract
Twin reversed arterial perfusion sequence (TRAP) is a rare complication of monochorionic twins (MC). This study aimed to describe and compare the short- and long-term outcomes of MC pregnancies with the TRAP sequence treated with two different techniques: interstitial fetal laser (IFL) (n = 22) versus endoscopic cord occlusion (CO) (n = 24). The study population included 46 MC pregnancies with TRAP. Pregnancy loss within 2 weeks after the procedure occurred in 27% of cases (6/22) in the group treated with IFL and in 8% of cases (2/24) in the group treated with CO. The survival rate of the pump twin was 73% (16/22) in the IFL group and 83% (20/24) in the group treated with CO. The median gestational age at birth was 38 weeks in the group treated with IFL and 35 weeks in the group treated with CO. The rate of preterm birth before 34 weeks was 12.5% (2/16) in the group treated with IFL and 32% (7/22) in the group treated with CO. In the group treated with IFL, there were no cases of neurological disabilities reported by the parents compared to three cases in the CO group. IFL is associated with a higher risk of early pregnancy loss; however, if the pregnancy progresses, it is associated with lower risks of preterm birth and neurological disabilities in the survivors.
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Affiliation(s)
- Izabela Walasik
- I Department of Obstetrics and Gynecology, Medical University of Warsaw, 02-091 Warsaw, Poland; (I.W.); (M.L.); (A.L.)
| | - Magdalena Litwinska
- I Department of Obstetrics and Gynecology, Medical University of Warsaw, 02-091 Warsaw, Poland; (I.W.); (M.L.); (A.L.)
| | - Katarzyna Janiak
- Department of Gynecology, Fertility and Fetal Surgery, Polish Mother’s Memorial Hospital in Lodz, 93-338 Lodz, Poland; (K.J.); (K.S.); (P.K.)
| | - Krzysztof Szaflik
- Department of Gynecology, Fertility and Fetal Surgery, Polish Mother’s Memorial Hospital in Lodz, 93-338 Lodz, Poland; (K.J.); (K.S.); (P.K.)
| | - Piotr Kaczmarek
- Department of Gynecology, Fertility and Fetal Surgery, Polish Mother’s Memorial Hospital in Lodz, 93-338 Lodz, Poland; (K.J.); (K.S.); (P.K.)
| | - Artur Ludwin
- I Department of Obstetrics and Gynecology, Medical University of Warsaw, 02-091 Warsaw, Poland; (I.W.); (M.L.); (A.L.)
| | - Ewelina Litwinska
- I Department of Obstetrics and Gynecology, Medical University of Warsaw, 02-091 Warsaw, Poland; (I.W.); (M.L.); (A.L.)
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Nicolì P, Damiani GR, Gaetani M, Dellino M, Vitagliano A, Malvasi A, Cazzato G, Cascardi E, Marzullo A, Alfonso R, Cicinelli E, Vimercati A. "The Strange Case of Dr Pump and Mr Acardiac": The Twin Reversed Arterial Perfusion (TRAP) Sequence in Two Monochorionic Monoamniotic (MCMA) Twin Pregnancies-Diagnosis, Prognosis and Management: Review of Literature. Diagnostics (Basel) 2023; 13:3109. [PMID: 37835852 PMCID: PMC10572342 DOI: 10.3390/diagnostics13193109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/22/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
The Twin Reversed Arterial Perfusion (TRAP) Sequence is an extremely rare complication of monochorionic twin pregnancies, with one severely malformed twin (the "acardiac") lacking autonomous placental blood supply and being perfused by the co-twin (the "pump"), through arterio-arterial (and sometimes also veno-venous) vascular anastomoses located on the placental surface. The prognosis is poor: mortality is 100% in the acardiac twin because of its severe malformations and about 50-55% in the pump twin, mainly due to heart failure and prematurity. So, the goal of perinatal management of the TRAP twin pregnancy is to deliver a healthy and near-term pump twin without heart failure or fetal hydrops. Intuitively, the earlier the diagnosis, the better the outcome. Herein, we report two cases of monochorionic monoamniotic (MCMA) twin pregnancies complicated by the TRAP Sequence, which are of interest since the objective of early diagnosis was achieved by means of transvaginal and 3D ultrasound, two techniques which revealed themselves as being useful to this purpose but are underused in the literature. The second aim of this study is to provide an overview of literature data about the diagnosis, prognosis establishment, and management of this rare condition, which are still debated and unclear due to negligible poor-quality evidence.
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Affiliation(s)
- Pierpaolo Nicolì
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Gianluca Raffaello Damiani
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Maria Gaetani
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Miriam Dellino
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Amerigo Vitagliano
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | | | - Gerardo Cazzato
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Eliano Cascardi
- Department of Medical Sciences, University of Turin, 10124 Turin, Italy
- Pathology Unit, FPO-IRCCS Candiolo Cancer Institute, 10060 Candiolo, Italy
| | - Andrea Marzullo
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Raffaello Alfonso
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Ettore Cicinelli
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Antonella Vimercati
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
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Rahimi-Sharbaf F, Shirazi M, Hessami K, Saleh M, Golshahi F, Saeedi S, Shirdel Abdolmaleki A, Mousavi Vahed SH, Nouri B, Sahebdel B. Radiofrequency Ablation and Intrauterine Transfusion in a Delayed Diagnosed Acardiac Twin Pregnancy. Case Rep Obstet Gynecol 2023; 2023:3243820. [PMID: 37680203 PMCID: PMC10482538 DOI: 10.1155/2023/3243820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 12/21/2022] [Accepted: 07/11/2023] [Indexed: 09/09/2023] Open
Abstract
Twin reversed arterial perfusion (TRAP) sequence or acardiac twin is a rare and severe complication of monochorionic multiple pregnancies. Acardiac twin accounts for 10% of all TRAP sequences, which is the most morphologically developed acardius. We present an undiagnosed TRAP sequence case up to 24 weeks of gestation who underwent successful amnioreduction, radiofrequency ablation (RFA), and intrauterine transfusion (IUT). During follow-up, hydrops of surviving co-twin disappeared, and fetal heart function improved. Finally, a healthy girl weighing 2400 g was born at 36 weeks of gestation. To our knowledge, this is the first reported acardiac twin pregnancy, which requires IUT, in addition to RFA, due to late diagnosis. Therefore, this case report presents successful management options for TRAP sequence cases diagnosed late in pregnancy.
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Affiliation(s)
- Fatemeh Rahimi-Sharbaf
- Department of Obstetrics and Gynecology, Maternal Fetal and Neonatal Research Center, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahboobeh Shirazi
- Department of Obstetrics and Gynecology, Maternal Fetal and Neonatal Research Center, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Kamran Hessami
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Maasoumeh Saleh
- Department of Obstetrics and Gynecology, Maternal Fetal and Neonatal Research Center, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Department of Obstetrics and Gynecology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Golshahi
- Department of Obstetrics and Gynecology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Sara Saeedi
- Department of Obstetrics and Gynecology, Maternal Fetal and Neonatal Research Center, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | | | - Behnaz Nouri
- Department of Community Medicine, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Behrokh Sahebdel
- Department of Obstetrics and Gynecology, Maternal Fetal and Neonatal Research Center, Yas Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Hans P. Twin Reversed Arterial Perfusion. Cureus 2022; 14:e31116. [DOI: 10.7759/cureus.31116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2022] [Indexed: 11/07/2022] Open
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Wu T, Gong X, Wang X, Li L, Chen Z, Yuan P, Xie J, Gong L, Wang X, Zhao Y, Wei Y. Perinatal and neurodevelopmental outcome in complicated monochorionic pregnancy after selective fetal reduction: radiofrequency ablation vs microwave ablation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:506-513. [PMID: 35468234 DOI: 10.1002/uog.24919] [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: 05/08/2021] [Revised: 04/02/2022] [Accepted: 04/08/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES To summarize our experience in the application of radiofrequency ablation (RFA) and microwave ablation (MWA) for selective fetal reduction in complicated monochorionic pregnancies and compare the perinatal outcome of the two techniques. METHODS This was a retrospective study of data from a consecutive cohort of all monochorionic twin pregnancies that underwent selective fetal reduction with RFA or MWA at Peking University Third Hospital, Beijing, China from January 2012 to December 2018. All surviving cotwins were followed up to assess their neurodevelopment using the Age & Stage Questionnaire, Chinese version. Perinatal and neurodevelopmental outcomes were compared between the RFA and MWA groups. We also fitted multivariable models to test the association between procedure-related factors and the main perinatal outcomes, including preterm birth (PTB) < 37 weeks' gestation, intrauterine fetal death (IUFD) of the cotwin, adverse outcome (defined as occurrence of IUFD of the cotwin, termination of pregnancy or PTB < 28 weeks) and overall survival. RESULTS In total, 45 cases (42 twin and three triplet pregnancies) underwent RFA and 126 cases (105 twin and 21 triplet pregnancies) underwent MWA. The overall survival rates in monochorionic diamniotic twin pregnancies were similar between the RFA and MWA groups (61.0% vs 67.0%; P = 0.494). However, pregnancies whose indication for fetal reduction was selective intrauterine growth restriction or twin reversed arterial perfusion had higher overall survival rates (75.5% and 82.6%, respectively) compared with those in other indication groups. A total of 104 children were followed up (20 in the RFA group and 84 in the MWA group); four (20.0%) and eight (9.5%) children were assessed as having overall developmental delay in the RFA and MWA groups, respectively, with no significant difference between the two groups. Multivariable analyses showed that procedure indication, number of ablation cycles and gestational age at procedure were associated significantly with the main perinatal outcomes. CONCLUSIONS RFA and MWA for selective fetal reduction in complicated monochorionic pregnancies can achieve similar overall survival rate and neurodevelopmental outcome, but MWA is associated with a lower risk of preterm birth. Moreover, procedure-related factors are associated significantly with perinatal outcome. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- T Wu
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - X Gong
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - X Wang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - L Li
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Z Chen
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - P Yuan
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - J Xie
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - L Gong
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - X Wang
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - Y Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Y Wei
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
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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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Brock CO, Johnson A. Twin reverse arterial perfusion: Timing of intervention. Best Pract Res Clin Obstet Gynaecol 2022; 84:127-142. [PMID: 35466064 DOI: 10.1016/j.bpobgyn.2022.03.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/13/2022] [Indexed: 11/24/2022]
Abstract
Twin reverse arterial perfusion (TRAP) sequence is a severe anomaly in monochorionic twins where one twin has profound corporeal underdevelopment and acardia. The normal "pump" co-twin provides blood flow to the acardiac twin through placental anastomoses which may lead to cardiac failure and pump twin demise as well as preterm delivery from severe polyhydramnios. Treatments include radiofrequency ablation, bipolar cord coagulation, and intrafetal laser with each aimed at occluding blood flow to the acardiac twin. However, none of these modalities has proven superior in terms of either pump twin survival or minimization of complications, including preterm premature rupture of membranes, preterm birth, or unexpected co-twin demise. The optimal timing of treatment is also unknown, without clear indications for intervention versus expectant management. Very early treatment of TRAP (i.e., <16 weeks) has been proposed to reduce first-trimester demise; however, this approach remains experimental. Further investigation is required to determine the best treatment and timing of intervention for TRAP.
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Affiliation(s)
- Clifton O Brock
- Department of Obstetrics, Gynecology and Reproductive Services, University of Texas Health Science Center at Houston, United States; The Fetal Center at Children's Memorial Hermann Hospital, United States
| | - Anthony Johnson
- Department of Obstetrics, Gynecology and Reproductive Services, University of Texas Health Science Center at Houston, United States; The Fetal Center at Children's Memorial Hermann Hospital, United States.
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11
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Wu T, Chen Z, Yin X, Shi H, Niu J, Xie J, Wei Y, Wang X. Perinatal outcomes after selective feticide via umbilical cord occlusion in complicated monochorionic pregnancies: A systematic review and meta-analysis. Prenat Diagn 2021; 42:37-48. [PMID: 34699084 DOI: 10.1002/pd.6064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 07/14/2021] [Accepted: 10/19/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE We aimed to compare perinatal outcomes between umbilical cord occlusion techniques in monochorionic pregnancies, including umbilical cord ligation, fetoscopic laser coagulation, interstitial laser coagulation, bipolar cord occlusion, radiofrequency ablation, and microwave ablation. METHODS This study was registered with PROSPERO (CRD42020158861). PubMed, Web of Science, Cochrane Library, and Embase were searched for studies published up to May 2020. The DerSimonian-Laird random-effects model was used for the meta-analysis. Subgroup analyses were performed to compare the outcomes among the six techniques. Meta-regression was used to adjust for confounders. RESULTS Thirty-four studies with 1646 participants were included. The overall survival was 76.5% after umbilical cord ligation, 78.8% after fetoscopic laser coagulation, 60.3% after interstitial laser coagulation, 79.2% after bipolar cord occlusion, 77.5% after radiofrequency ablation, and 75.0% after microwave ablation. Subgroup comparison showed the rates of overall survival and preterm premature rupture of membranes were not significant different among six techniques. However, rates of fetal loss, premature birth, live birth, and neonatal death differed significantly among the six groups. CONCLUSIONS The choice of umbilical cord occlusion techniques will affect perinatal outcomes. We suggested that the choice of umbilical cord occlusion techniques should fully consider these differences among techniques.
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Affiliation(s)
- Tianchen Wu
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - Ziyi Chen
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Xiaohan Yin
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - Huifeng Shi
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Jieqiong Niu
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - Jialei Xie
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - Yuan Wei
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Xiaoli Wang
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China.,Key Laboratory of Reproductive Health, National Health Commission, Beijing, China
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12
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Ozawa K, Wada S, Muromoto J, Sugibayashi R, Wada YS, Ito Y, Sago H. Long-term neurodevelopmental outcomes of the pump twin in twin reversed arterial perfusion sequence treated by radiofrequency ablation. Prenat Diagn 2021; 41:1575-1581. [PMID: 34545602 PMCID: PMC9291518 DOI: 10.1002/pd.6048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/02/2021] [Accepted: 09/11/2021] [Indexed: 11/29/2022]
Abstract
Objectives To assess long‐term neurodevelopmental outcomes in children after radiofrequency ablation (RFA) for twin reversed arterial perfusion (TRAP) sequence. Methods This cross‐sectional study included children who underwent RFA for the TRAP sequence between 2012 and 2018. We assessed neurodevelopment in children using the Kinder Infant Development Scale, a validated questionnaire. The developmental quotient (DQ) assessed in nine subscales was calculated as the developmental age divided by the chronological age. Neurodevelopmental delay (NDD) was defined as a DQ of <70 points. Results In total, 38 children from 37 pregnancies underwent RFA for the TRAP sequence during the study period; 6 fetuses died in utero. We sent the questionnaire to the parents of the 32 surviving children and obtained answers for 27 (84%). The median age at the assessment was 2 years and 5 months old. The median total DQ was 111 (80–150). Most median DQs in the nine subscales were above 70. The incidence of NDD was 0% (0/27). There were no marked differences in DQ by chorionicity. Conclusions Children who survived after RFA for TRAP sequence showed favorable long‐term neurodevelopmental outcomes. Radiofrequency ablation seems to rarely affect fetal neurodevelopment. Pregnant women with TRAP sequence are encouraged to be treated by RFA. What's already known about this topic?Radiofrequency ablation (RFA), which induces the coagulation of tissue, is commonly used to treat twin reversed arterial perfusion (TRAP) sequence because of the minimal invasiveness of the technique. The survival rate of the pump twin of TRAP sequence treated by RFA is more than 80%; however, the long‐term neurodevelopmental outcomes of survivors have rarely been investigated.
What does this study add?Pump twins of TRAP sequence who survived after RFA showed favorable long‐term neurodevelopmental outcomes with a median developmental quotient of more than 100. Radiofrequency ablation in fetal surgery itself seems to rarely affect fetal neurodevelopment.
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Affiliation(s)
- Katsusuke Ozawa
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Seiji Wada
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Jin Muromoto
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Rika Sugibayashi
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yuka Sano Wada
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yushi Ito
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, 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.,Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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13
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Tang HR, Dai CY, Li J, Dai YM, Ru T, Li YL, Xiao X, Fan ZT, Hu YL, Zheng MM. Fetoscopy-guided bipolar cord coagulation in selective fetal reduction with complicated monochorionic diamniotic twins: a prospective cohort study. J Matern Fetal Neonatal Med 2021; 35:7744-7747. [PMID: 34470129 DOI: 10.1080/14767058.2021.1961725] [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: 10/20/2022]
Abstract
OBJECTIVE To assess the feasibility of fetoscopy-guided bipolar umbilical cord coagulation for selective fetal reduction in complicated monochorionic diamniotic (MCDA) twin pregnancies. METHODS MCDA twins undergoing fetoscopy-guided bipolar cord coagulation (BCC) were enrolled prospectively between December 2015 to March 2020 in a fetal medicine center. RESULTS Twenty-three cases undergoing fetoscopy-guided BCC were finally analyzed, including 11 cases for type 2 selective intrauterine growth restriction, 4 cases for twin-twin transfusion syndrome, and 8 cases for a severe discordant anomaly. The overall survival rate was 78.3% (18/23). CONCLUSIONS Fetoscopy-guided BCC is effective for selective fetal reduction in complicated monochorionic twin pregnancies.
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Affiliation(s)
- Hui R Tang
- Department of Obstetrics and Gynecology, the Affiliated Drum and Tower Hospital of Medical School of Nanjing University, Nanjing, China
| | - Chen Y Dai
- Department of Obstetrics and Gynecology, the Affiliated Drum and Tower Hospital of Medical School of Nanjing University, Nanjing, China
| | - Jie Li
- Department of Obstetrics and Gynecology, the Affiliated Drum and Tower Hospital of Medical School of Nanjing University, Nanjing, China
| | - Yi M Dai
- Department of Obstetrics and Gynecology, the Affiliated Drum and Tower Hospital of Medical School of Nanjing University, Nanjing, China
| | - Tong Ru
- Department of Obstetrics and Gynecology, the Affiliated Drum and Tower Hospital of Medical School of Nanjing University, Nanjing, China
| | - Ya L Li
- Department of Obstetrics and Gynecology, the Affiliated Drum and Tower Hospital of Medical School of Nanjing University, Nanjing, China
| | - Xian Xiao
- Department of Obstetrics and Gynecology, the Affiliated Drum and Tower Hospital of Medical School of Nanjing University, Nanjing, China
| | - Zhong T Fan
- Department of Obstetrics and Gynecology, the Affiliated Drum and Tower Hospital of Medical School of Nanjing University, Nanjing, China
| | - Ya L Hu
- Department of Obstetrics and Gynecology, the Affiliated Drum and Tower Hospital of Medical School of Nanjing University, Nanjing, China
| | - Ming M Zheng
- Department of Obstetrics and Gynecology, the Affiliated Drum and Tower Hospital of Medical School of Nanjing University, Nanjing, China
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14
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Huang G, Liao H, Hu Q, Wang X, Yu H. Intrafetal laser therapy in a monochorionic diamniotic triplet pregnancy with two acardiac fetuses: a case report and literature review. BMC Pregnancy Childbirth 2021; 21:245. [PMID: 33757441 PMCID: PMC7989209 DOI: 10.1186/s12884-021-03716-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 03/15/2021] [Indexed: 11/10/2022] Open
Abstract
Background Monochorionic diamniotic triplet pregnancies are rare. Twin reversed arterial perfusion sequence in monochorionic triplet pregnancies is extremely rare, and it is associated with high perinatal morbidity and mortality rates in the “pump fetus.” Case presentation We reported a case of monochorionic diamniotic triplet pregnancy with twin reversed arterial perfusion sequence, including two acardiac fetuses sharing a single amniotic sac and a normal fetus in another amniotic sac. Due to rapid growth of the acardiac fetuses, intrafetal laser therapy was performed in both of them under ultrasound guidance at 15 weeks +5 days. Subsequently, regular and careful antenatal care including fetal ultrasonography and doppler and fetal echocardiography was conducted. At 37 weeks +4 days, a healthy female baby weighing 2510 g was delivered. The baby was followed up and now at 11 months old is in good health. Conclusions Twin reversed arterial perfusion sequence in monochorionic triplet pregnancy should be diagnosed early by ultrasound imaging during pregnancy. Individualized management should be based on clinical conditions to improve the perinatal outcome of the pump twin. Intrafetal laser therapy could be an alternative procedure when intrauterine intervention is required.
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Affiliation(s)
- Guiqiong Huang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, 3rd section, South Renmin Road, Sichuan, 610041, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Hua Liao
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, 3rd section, South Renmin Road, Sichuan, 610041, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Qing Hu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, 3rd section, South Renmin Road, Sichuan, 610041, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Xiaodong Wang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, 3rd section, South Renmin Road, Sichuan, 610041, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Haiyan Yu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, 3rd section, South Renmin Road, Sichuan, 610041, Chengdu, China. .,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China.
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15
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Mon A, Yip J, Zalud I, Thompson KS. Monochorionic Triplet Pregnancies With Twin Reversed Arterial Perfusion and Acardiac Triplet: Report of Two Cases and Literature Review. Pediatr Dev Pathol 2021; 24:142-147. [PMID: 33439111 DOI: 10.1177/1093526620984143] [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] [Indexed: 11/16/2022]
Abstract
TRAP pregnancies involving monochorionic triplets are extremely rare, calculated to be 1 in 4.5 million. We report two cases of monochorionic triplet pregnancies with an acardiac triplet. In one case, the mother was a 33-year-old G2P1 who underwent dilation and evacuation at 20 weeks due to poor prognosis. The other case involved a 21-year-old G1P0 mother presenting in advanced preterm labor at 21 weeks who elected expectant management. Seventeen cases of monochorionic triplets with TRAP were identified in the literature. Invasive intervention was performed in 10 cases; 9 cases resulted in the survival of the nonacardiac twins and 1 case resulted in the survival of 1 fetus. Our two cases had common sonographic features which included polyhydramnios of all fetuses. Placental features shared between both cases included being large for gestational age and velamentous insertion of the acardiac twin. The acardiac twins in both of our cases were hydropic and demonstrated developed pelvis and lower extremities. One had an omphalocele. Most case reports in the literature review demonstrate similar findings. Two cases of monochorionic triplets with TRAP and acardiac twin are herein described. Successful treatment by invasive interventions have been described in this condition, highlighting the importance of early diagnosis.
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Affiliation(s)
- Ami Mon
- Department of Pathology, John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawai'i
| | - James Yip
- Department of Pathology, John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawai'i
| | - Ivica Zalud
- Department of Obstetrics, Gynecology and Women's Health, John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawai'i
| | - Karen S Thompson
- Department of Pathology, John A. Burns School of Medicine, University of Hawai'i, Honolulu, Hawai'i.,Clinical Laboratories of Hawaii, Honolulu, Hawai'i
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16
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Wang H, Zhou Q, Wang X, Song J, Chen P, Wang Y, Li L, Li H. Influence of indications on perinatal outcomes after radio frequency ablation in complicated monochorionic pregnancies: a retrospective cohort study. BMC Pregnancy Childbirth 2021; 21:41. [PMID: 33422050 PMCID: PMC7797138 DOI: 10.1186/s12884-020-03530-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 12/26/2020] [Indexed: 02/03/2023] Open
Abstract
Background Radiofrequency ablation (RFA) is recommended to prevent potential neurological injury or intrauterine foetal death (IUFD) of the co-twin(s) in complicated monochorionic (MC) pregnancies. However, the impacts of various indications on the pregnancy outcome following RFA remain unclear. This study aimed to determine how the indications influence the perinatal outcomes in complicated MC pregnancies undergoing radiofrequency ablation. Methods This was a retrospective cohort study performed in a single centre. All consecutive MC pregnancies treated with RFA between July 2011 and July 2019 were included. The adverse perinatal outcomes and the survival rate were analysed based on various indications. The continuous variables with and without normal distribution were compared between the groups using Student’s t-test and Mann–Whitney U test, respectively, and for categorical variables, Chi-square and Fisher’s exact tests were used. P < 0.05 indicated a significant difference. Results We performed 272 RFA procedures in 268 complicated MC pregnancies, including 60 selective intrauterine growth restriction (sIUGR), 64 twin–twin transfusion syndrome (TTTS), 12 twin reversed arterial perfusion sequence (TRAPs), 66 foetal anomaly and 66 elective foetal reduction (EFR) cases. The overall survival rate of the co-twin was 201/272 (73.9%). The overall technical successful rate was determined at 201/263 (76.7%). The IUFD rate in the co-twin was 20/272 (7.4%). The TTTS group had recorded the lowest survival rate (37/64, 57. 8%), and the survival rate was significantly correlated with Quintero stages (P = 0.029). Moreover, the sIUGR III subgroup had a lower survival rate compared with sIUGR II (55.6%, versus 84.3%). The subgroup of foetal anomaly of gastroschisis or exomphalos had the highest IUFD rate (4/10, 40%), followed by sIUGR III (2/9, 22.2%) and dichorionic triamniotic (DCTA) subgroup (8/46, 17.9%). In EFR group, eight IUFD cases were all coming from the DCTA subgroup and received RFA before 17 weeks. Conclusions The perinatal outcome of RFA was correlated with the indications, with the lowest survival rate in TTTS IV and the highest IUFD incidence in abdominal wall defect followed by sIUGR III. Elective RFA after 17 weeks may prevent IUFD in DCTA pregnancies.
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Affiliation(s)
- Hongmei Wang
- Department of Obstetrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Qian Zhou
- Department of Obstetrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xietong Wang
- Department of Obstetrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China.,Department of Obstetrics, Maternal Child Health Care Hospital of Shandong Province, Jinan, Shandong, China.,Key Laboratory of Birth Regulation and Control Technology of National Health Commission of China, Maternal Child Health Care Hospital of Shandong Province, Jinan, Shandong, China
| | - Jia Song
- Department of Neonatology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Pengzheng Chen
- Department of Obstetrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Yanyun Wang
- Department of Obstetrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Lei Li
- Department of Obstetrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Hongyan Li
- Department of Obstetrics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China.
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17
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Shinar S, Agrawal S, El-Chaâr D, Abbasi N, Beecroft R, Kachura J, Keunen J, Seaward G, Van Mieghem T, Windrim R, Ryan G. Selective fetal reduction in complicated monochorionic twin pregnancies: A comparison of techniques. Prenat Diagn 2020; 41:52-60. [PMID: 32939784 DOI: 10.1002/pd.5830] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 09/09/2020] [Accepted: 09/12/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To compare perinatal outcomes associated with three methods of selective reduction in complicated monochorionic (MC) twin pregnancies: bipolar cord coagulation (BC), fetoscopic or ultrasound guided laser cord occlusion and radiofrequency ablation (RFA). METHODS Retrospective cohort study of complicated MC twin pregnancies undergoing selective fetal reduction at a tertiary fetal center over a 20-year period. Obstetric and perinatal outcomes were compared. RESULTS 105 procedures met inclusion criteria: 74 RFAs, 17 lasers and 14 BCs. Procedure duration was significantly shorter for RFA (27.4 ± 15.8 minutes) compared to BC (91.7 ± 38.7 minutes) and laser (83.4 ± 40.4 minutes), P < .0001). The incidence of preterm prelabor rupture of membranes (PPROM) and co-twin demise did not differ between groups, however preterm delivery <34 weeks occurred less frequently following RFA (29.7%), compared to laser (64.7%) or BC (42.9%) (P = .02); delivery <37 weeks was also less frequent following RFA (45.9%), compared to laser (76.5%) or BC (78.6%)(P = .01). The difference in preterm birth<34 weeks between RFA and laser was maintained after adjusting for cord occlusion indication and amnionicity (OR 3.96, 95% CI 1.27-12.31). CONCLUSIONS In our experience, RFA procedures were simpler, faster and associated with a lower risk of preterm delivery <34 and <37 weeks, compared to laser or BC.
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Affiliation(s)
- Shiri Shinar
- Ontario Fetal Centre, Fetal Medicine Unit, Dept. Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Swati Agrawal
- Ontario Fetal Centre, Fetal Medicine Unit, Dept. Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Darine El-Chaâr
- Ontario Fetal Centre, Fetal Medicine Unit, Dept. Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Nimrah Abbasi
- Ontario Fetal Centre, Fetal Medicine Unit, Dept. Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Robert Beecroft
- University of Toronto, Toronto, Ontario, Canada.,Dept. Medical Imaging, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - John Kachura
- University of Toronto, Toronto, Ontario, Canada.,Dept. Medical Imaging, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Johannes Keunen
- Ontario Fetal Centre, Fetal Medicine Unit, Dept. Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Gareth Seaward
- Ontario Fetal Centre, Fetal Medicine Unit, Dept. Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Tim Van Mieghem
- Ontario Fetal Centre, Fetal Medicine Unit, Dept. Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Rory Windrim
- Ontario Fetal Centre, Fetal Medicine Unit, Dept. Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Greg Ryan
- Ontario Fetal Centre, Fetal Medicine Unit, Dept. Obstetrics & Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Dept. Medical Imaging, Mount Sinai Hospital, Toronto, Ontario, Canada
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18
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Yi J, Wu X. Twin reversed arterial perfusion sequence: A case report. Int J Gynaecol Obstet 2020; 152:450-451. [PMID: 32892359 DOI: 10.1002/ijgo.13369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 08/05/2020] [Accepted: 09/01/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Jiao Yi
- Department of Obstetrics and Gynecology, Maternal and Child Health Care Hospital affiliated with Anhui Medical University, Anhui Maternal and Child Health Care Hospital, Hefei, China
| | - Xiumei Wu
- Department of Obstetrics and Gynecology, Maternal and Child Health Care Hospital affiliated with Anhui Medical University, Anhui Maternal and Child Health Care Hospital, Hefei, China
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19
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Wataganara T, Phithakwatchara N, Pooliam J, Jaingam S, Thongkloung P, Mongkolchat N, Viboonchart S, Nawapun K. Morphology, intrafetal vascular pattern, and umbilical artery Doppler indices of acardiac twins. Prenat Diagn 2020; 40:958-965. [PMID: 32297344 DOI: 10.1002/pd.5710] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/10/2020] [Accepted: 04/12/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Twin reversed arterial perfusion (TRAP) sequence consists of acardiac twin (A) paradoxically perfused by pump twin (P) through an umbilical artery (UA). We proposed characterization of acardiac twins with intrafetal vascular pattern (IVP), and assessed its correlation with morphology and UA Doppler indices. METHODS We prospectively evaluated 21 cases of TRAP sequence. Morphology (acardia vs hemicardia) and IVP (simple vs complex) of acardiac twins were characterized with ultrasound and color Doppler. Twins weight ratio (A/P Wt) and UA Doppler indices of acardiac and pump twins including (1) difference of systolic/diastolic ratio (UA ∆S/D), (2) difference of resistance index (UA ∆RI), and (3) ratio of pulsatility index (UA PI A/P) were calculated. RESULTS The median (min, max) gestational age at diagnosis was 18 (11, 27) weeks. Acardia (n = 14) were associated with simple IVP (n = 16) (P < .05). After exclusion of acardia with complex IVP (n = 1), the A/P Wt, UA ∆S/D, UA ∆RI, and UA PI A/P of acardia with simple IVP (n = 13), hemicardia with simple IVP (n = 3), and hemicardia with complex IVP (n = 4) were not significantly different (P > .05). CONCLUSIONS Most of acardiac twins were acardia with simple IVP. Morphology and IVP of acardiac twins were not associated with UA Doppler indices.
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Affiliation(s)
- Tuangsit Wataganara
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mahidol University, Bangkok, Thailand
| | - Nisarat Phithakwatchara
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mahidol University, Bangkok, Thailand
| | - Julaporn Pooliam
- Division of Clinical Epidemiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Suparat Jaingam
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mahidol University, Bangkok, Thailand
| | - Piyatida Thongkloung
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mahidol University, Bangkok, Thailand
| | - Nadda Mongkolchat
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mahidol University, Bangkok, Thailand
| | - Sommai Viboonchart
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mahidol University, Bangkok, Thailand
| | - Katika Nawapun
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Mahidol University, Bangkok, Thailand
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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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Ziki EM, Chirenje ZM, Madziyire MG. A case of twin reversed arterial perfusion (TRAP) sequence managed conservatively. Pan Afr Med J 2019; 32:54. [PMID: 31143359 PMCID: PMC6522165 DOI: 10.11604/pamj.2019.32.54.15480] [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: 03/15/2018] [Accepted: 12/28/2018] [Indexed: 11/25/2022] Open
Abstract
The TRAP sequence, also known as acardiac twinning is a rare complication that is unique to monochorioinic multiple pregnancies affecting 1% of monochorioinic pregnancies and about 1 in 35000 of all pregnancies. In TRAP, blood flows from the umbilical artery of the pump twin to the umbilical artery of the perfused twin through artery to artery (AA) anastomosis. The perfused twin has poor development of the upper extremities and the normal or pump twin is at risk of a poor perinatal outcome. This is a report of a patient with TRAP sequence diagnosed in the second trimester who was managed conservatively and had a good outcome for the normal twin.
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Affiliation(s)
- Enesia Mudenha Ziki
- Department of Obstetrics and Gynaecology, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
| | - Zvavahera Mike Chirenje
- Department of Obstetrics and Gynaecology, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
| | - Mugove Gerald Madziyire
- Department of Obstetrics and Gynaecology, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
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22
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Aoyagi Y, Kai K, Sumie M, Fujiyoshi N, Furukawa Y, Narahara H. Therapeutic dilemma in twin reversed arterial perfusion sequence. SAGE Open Med Case Rep 2019; 7:2050313X19836342. [PMID: 30899512 PMCID: PMC6419244 DOI: 10.1177/2050313x19836342] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 02/12/2019] [Indexed: 11/18/2022] Open
Abstract
The dissemination of minimally invasive in utero surgery reduced the mortality of twin reversed arterial perfusion sequence, but the mortality of expectantly treated surgical candidates remains high. A 26-year-old, non-parous, Japanese woman at 13 weeks of gestation had been diagnosed with twin reversed arterial perfusion sequence and was judged as a surgical candidate for radiofrequency ablation. However, she did not undergo surgery because of the anatomical location of the acardiac twin. At 18 weeks of gestation, the blood flow to the acardiac twin disappeared spontaneously. The pump twin began to demonstrate fetal growth retardation during the third trimester. The patient delivered a 1891 g female at term. We macroscopically identified the cause of the fetal growth retardation as velamentous insertion of the umbilical cord and microscopically diagnosed the acardiac twin with acardiac acephalus. We should give the same attention to the management of post–twin reversed arterial perfusion sequence as twin reversed arterial perfusion sequence itself.
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Affiliation(s)
- Yoko Aoyagi
- Department of Obstetrics and Gynecology, Nakatsu Municipal Hospital, Nakatsu, Japan
| | - Kentaro Kai
- Department of Obstetrics and Gynecology, Nakatsu Municipal Hospital, Nakatsu, Japan
| | - Masahiro Sumie
- Perinatal Care Center, Fukuoka Children's Hospital, Fukuoka, Japan
| | | | - Yuichi Furukawa
- Department of Obstetrics and Gynecology, Nakatsu Municipal Hospital, Nakatsu, Japan
| | - Hisashi Narahara
- Department of Obstetrics and Gynecology, Faculty of Medicine, Oita University, Yufu, Japan
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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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Meng X, Yuan P, Gong L, Wang X, Wu T, Wei Y, Zhao Y. Forty-five consecutive cases of complicated monochorionic multiple pregnancy treated with microwave ablation: A single-center experience. Prenat Diagn 2019; 39:293-298. [PMID: 30677152 DOI: 10.1002/pd.5423] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 12/24/2018] [Accepted: 01/21/2019] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To describe our preliminary experience in the application of microwave ablation for selective fetal reduction in complicated monochorionic multiple pregnancies. METHODS In this prospective study, 45 consecutive complicated monochorionic multiple pregnancies that underwent microwave ablation for selective fetal reduction from July 2015 to February 2017 were analyzed from the first case onward. All patients were managed at the Peking University Third Hospital in Beijing, China. RESULTS There were 45 cases (twins in 40 and triplets in five) treated by microwave ablation. The median gestational age at surgery was 21.3 weeks (range, 15.9-25.7 wk), with a mean total ablation time of 8.5 ± 4.2 (7.2-9.7) minutes. There were 12 (26.7%) cases of postprocedural fetal loss. Thirty-three women delivered alive at a median gestational age of 37.6 weeks (range, 28.6-40.4 wk). There were no neonatal deaths in our cohort, and the overall survival rate was 73.3% (33/45). Preterm premature rupture of membranes occurred in 9 (20.0%) cases with a median of 7.0 weeks (range, 0.9-16.3 wk) after the surgery. None of the surviving cotwins had evidence of thermal injury or neurological abnormalities. CONCLUSION Microwave ablation appears to be a safe and effective method for selective feticide in complicated monochorionic pregnancies.
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Affiliation(s)
- Xinlu Meng
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Pengbo Yuan
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Lijun Gong
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Xueju Wang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Tianchen Wu
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - Yuan Wei
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Yangyu Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
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Abstract
Evaluation of fetal cardiac function is one of the most important components of fetal echocardiography. Fetal cardiac dysfunction is closely linked to risk of intrauterine fetal demise, in many, but not all cases is indicative of worse postnatal prognosis and may prompt the use of medications or interventions to optimize outcomes. There may be implications for termination versus continuation of pregnancy, an indication for early delivery, a change in location and even mode of delivery. In extreme cases, fetal cardiac dysfunction may prompt prenatal or early neonatal listing for cardiac transplantation. There are several important differences between the fetal and postnatal circulatory physiology which affect echocardiographic assessment of cardiac dysfunction. In this review, we examine the echocardiographic findings according to their underlying pathophysiology with reference to common causes.
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Affiliation(s)
- Luke Eckersley
- Fetal & Neonatal Cardiology Program, Echocardiography Laboratory, Division of Cardiology, Departments of Pediatrics, Women & Children's Health Research, Mazankowski Alberta Heart Institutes, and Cardiovascular Research Centre, University of Alberta, Edmonton, AB, Canada
| | - Lisa K Hornberger
- Fetal & Neonatal Cardiology Program, Echocardiography Laboratory, Division of Cardiology, Departments of Pediatrics, Women & Children's Health Research, Mazankowski Alberta Heart Institutes, and Cardiovascular Research Centre, University of Alberta, Edmonton, AB, Canada.,Departments of Obstetrics & Gynecology, Women & Children's Health Research, Mazankowski Alberta Heart Institutes, and Cardiovascular Research Centre, University of Alberta, Edmonton, AB, Canada
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26
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Zhang ZT, Yang T, Liu CX, Li N. Treatment of twin reversed arterial perfusion sequence with radiofrequency ablation and expectant management: A single center study in China. Eur J Obstet Gynecol Reprod Biol 2018; 225:9-12. [PMID: 29626712 DOI: 10.1016/j.ejogrb.2018.03.046] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 03/20/2018] [Accepted: 03/23/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the treatment of pregnancies in different stages complicated by TRAP sequence at a single medical center in China. STUDY DESIGN A retrospective study evaluating 25 pregnancies with TRAP sequence was performed at Shengjing Hospital in Shenyang, Liaoning between 2012 and 2016. Patients were diagnosed by ultrasound and categorized into three groups (Ia, IIa and IIb) and were expectantly managed or performed RFA (radiofrequency ablation) according to their stage of TRAP sequence. Perinatal outcomes and survival rates were analyzed. RESULTS There were four cases in stage Ia, 19 cases in stage IIa, and two cases in stage IIb. Cases in stage Ia were expectantly managed. Among cases in stage IIa, we performed RFA (radiofrequency ablation) in 10 cases and expectant management in 6 cases, with the remainder of the patients refusing intrauterine treatment. We applied RFA to treat one case in stage IIb and the other was managed expectantly. For expectant management group and the RFA group, the survival rates were both 64%(7/11). All pump twins in stage Ia survived and the average gestational age at delivery was 37.9 weeks. In stage IIa, the overall survival rate of the pump twin was 70% (7/10) and the average gestational age at delivery was 35.8 weeks in cases treated by RFA. The survival rate was 50% (3/6) and the average gestational age at delivery was 32.8 weeks in expectantly managed cases in stage IIa. No pump twin survived in stage IIa without treatment (3 cases refused any therapy who were excluded) or in stage IIb. CONCLUSION Expectant management is effective for treatment of TRAP sequence in stage Ia. In stage IIa, RFA improves the prognosis of pump twins.
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Affiliation(s)
- Zhi-Tao Zhang
- Department of Gynaecology and Obstetrics, ShengJing Hospital Affiliated to China Medical University, Shen Yang City, Liao Ning Province, China
| | - Tian Yang
- Department of Gynaecology and Obstetrics, ShengJing Hospital Affiliated to China Medical University, Shen Yang City, Liao Ning Province, China
| | - Cai-Xia Liu
- Department of Gynaecology and Obstetrics, ShengJing Hospital Affiliated to China Medical University, Shen Yang City, Liao Ning Province, China.
| | - Na Li
- Department of Gynaecology and Obstetrics, ShengJing Hospital Affiliated to China Medical University, Shen Yang City, Liao Ning Province, China
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27
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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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28
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Abdel-Sattar M, Chon AH, Llanes A, Korst LM, Ouzounian JG, Chmait RH. Comparison of umbilical cord occlusion methods: Radiofrequency ablation versus laser photocoagulation. Prenat Diagn 2018; 38:110-116. [DOI: 10.1002/pd.5196] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 12/04/2017] [Accepted: 12/10/2017] [Indexed: 01/08/2023]
Affiliation(s)
- Mira Abdel-Sattar
- 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
| | - Arlyn Llanes
- 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
| | - Joseph G. Ouzounian
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine; University of Southern California; Pasadena CA USA
| | - Ramen H. Chmait
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine; University of Southern California; Pasadena CA USA
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