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Kontopoulos E, Quintero RA. Fetoscopic demonstration of feto-fetal hemorrhage before actual demise of a monochorionic twin, successful antenatal treatment, and narrative review of the literature. J Matern Fetal Neonatal Med 2023; 36:2215898. [PMID: 37290961 DOI: 10.1080/14767058.2023.2215898] [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: 04/17/2023] [Revised: 05/10/2023] [Accepted: 05/15/2023] [Indexed: 06/10/2023]
Abstract
Feto-fetal hemorrhage (FFH) through placental vascular anastomoses is believed to be responsible for the death or damage of a "second twin" after the demise of a "first twin (co-twin)" in monochorionic twin pregnancies. However, the timing of FFH has been difficult to determine. The resulting anemia in the surviving twin can be suspected by the finding of an elevated middle cerebral artery peak-systolic velocity (MCA-PSV), but this elevation may lag for at least 4 h after the demise of the first twin. Knowledge of the timing of FFH may have important clinical implications, as it may dictate if and when attempts to prevent death or damage to the second twin by delivery or intrauterine fetal transfusion would be warranted. We present a case that supports the notion that FFH occurs before the actual demise of the first twin. A review of the literature was also conducted.
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Affiliation(s)
- Eftichia Kontopoulos
- The USFetus Research Consortium, Miami, FL, USA
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Florida International University, Herbert Wertheim School of Medicine, Miami, FL, USA
- The Fetal Institute, Miami, FL, USA
| | - Ruben A Quintero
- The USFetus Research Consortium, Miami, FL, USA
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Florida International University, Herbert Wertheim School of Medicine, Miami, FL, USA
- The Fetal Institute, Miami, FL, USA
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2
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Bakhbakhi D, Siassakos D, Davies A, Merriel A, Barnard K, Stead E, Shakespeare C, Duffy JMN, Hinton L, McDowell K, Lyons A, Fraser A, Burden C. Interventions, outcomes and outcome measurement instruments in stillbirth care research: A systematic review to inform the development of a core outcome set. BJOG 2023; 130:560-576. [PMID: 36655361 DOI: 10.1111/1471-0528.17390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 10/08/2022] [Accepted: 10/26/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND A core outcome set could address inconsistent outcome reporting and improve evidence for stillbirth care research, which have been identified as an important research priority. OBJECTIVES To identify outcomes and outcome measurement instruments reported by studies evaluating interventions after the diagnosis of a stillbirth. SEARCH STRATEGY Amed, BNI, CINAHL, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, MEDLINE, PsycINFO, and WHO ICTRP from 1998 to August 2021. SELECTION CRITERIA Randomised and non-randomised comparative or non-comparative studies reporting a stillbirth care intervention. DATA COLLECTION AND ANALYSIS Interventions, outcomes reported, definitions and outcome measurement tools were extracted. MAIN RESULTS Forty randomised and 200 non-randomised studies were included. Fifty-eight different interventions were reported, labour and birth care (52 studies), hospital bereavement care (28 studies), clinical investigations (116 studies), care in a multiple pregnancy (2 studies), psychosocial support (28 studies) and care in a subsequent pregnancy (14 studies). A total of 391 unique outcomes were reported and organised into 14 outcome domains: labour and birth; postpartum; delivery of care; investigations; multiple pregnancy; mental health; emotional functioning; grief and bereavement; social functioning; relationship; whole person; subsequent pregnancy; subsequent children and siblings and economic. A total of 242 outcome measurement instruments were used, with 0-22 tools per outcome. CONCLUSIONS Heterogeneity in outcome reporting, outcome definition and measurement tools in care after stillbirth exists. Considerable research gaps on specific intervention types in stillbirth care were identified. A core outcome set is needed to standardise outcome collection and reporting for stillbirth care research.
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Affiliation(s)
| | | | - Anna Davies
- Centre for Academic Child Health, University of Bristol, Bristol, UK
| | | | | | - Emma Stead
- Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | | | | | - Lisa Hinton
- THIS Institute, University of Cambridge, Cambridge, UK
| | | | - Anna Lyons
- Northern General Hospital, Sheffield, UK
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Tedjawirja VN, van Klink JM, Haak MC, Klumper FJ, Middeldorp JM, Miller JL, Rosner M, Baschat AA, Lopriore E, Oepkes D. Questionable benefit of intrauterine transfusion following single fetal death in monochorionic twin pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:824-825. [PMID: 35137996 DOI: 10.1002/uog.24876] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/29/2022] [Accepted: 02/01/2022] [Indexed: 06/14/2023]
Affiliation(s)
- V N Tedjawirja
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M van Klink
- Department of Medical Psychology, Leiden University Medical Center, Leiden, The Netherlands
| | - M C Haak
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - F J Klumper
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - J M Middeldorp
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - J L Miller
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Baltimore, MD, USA
| | - M Rosner
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Baltimore, MD, USA
| | - A A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology and Obstetrics, Baltimore, MD, USA
| | - E Lopriore
- Department of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - D Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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Kanda M, Noguchi S, Yamamoto R, Kawaguchi H, Hayashi S, Murakoshi T, Ishii K. Perinatal outcomes of intrauterine transfusion for the surviving twin in monochorionic twin gestation involving a single fetal demise. J Obstet Gynaecol Res 2020; 46:1319-1325. [PMID: 32484289 DOI: 10.1111/jog.14338] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 04/22/2020] [Accepted: 05/12/2020] [Indexed: 11/30/2022]
Abstract
AIM This study aimed to evaluate the feasibility and outcome of intrauterine transfusion (IUT) for the surviving co-twin in monochorionic diamniotic (MCDA) twin gestations involving single intrauterine fetal death (sIUFD). METHODS Cases of MCDA twin gestations involving emergent IUT for co-twins experiencing acute feto-fetal hemorrhage (AFFH) subsequent to sIUFD during the second trimester were reviewed. Fetal anemia was confirmed via fetal blood sampling, and perinatal data were retrieved from medical charts to determine the outcomes of surviving co-twins. A poor outcome at 28 days of age was defined as fetal death, neonatal death or neurological impairment such as severe intraventricular hemorrhage or cystic periventricular leukomalacia (PVL). RESULTS This study included 16 cases of sIUFD diagnosed at a median of 22.5 weeks of gestation (range: 18-25 weeks). The median interval in hours between diagnosis of fetal demise and IUT was approximately 4.2 (0-22) hours. All cases achieved IUT without significant intraoperative complications. Four cases experienced a fetal loss of the co-twin, whereas 12 co-twins were born alive (including 9 preterm births), with only 1 poor outcome in a preterm infant with PVL. CONCLUSION IUT may be a feasible prenatal intervention for surviving co-twins with AFFH. However, more extensive or pooled studies are needed to determine the efficacy of this intervention.
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Affiliation(s)
- Masako Kanda
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Shohei Noguchi
- Division of Perinatology, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan
| | - Ryo Yamamoto
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Haruna Kawaguchi
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Shusaku Hayashi
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Takeshi Murakoshi
- Division of Perinatology, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Hamamatsu, Shizuoka, Japan
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
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5
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Iwagaki S, Takahashi Y, Chiaki R, Asai K, Matsui M, Katsura D. Case of resuscitation from cardiac failure by intrauterine transfusion after single fetal death in monochorionic twin pregnancy. J Obstet Gynaecol Res 2019; 45:2105-2110. [PMID: 31368163 DOI: 10.1111/jog.14082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 07/15/2019] [Indexed: 11/30/2022]
Abstract
In case of a single fetal death in monochorionic twin pregnancy, the surviving fetus is thought to become hypovolemic. However, there is no report of any evidence of fetal circulatory insufficiency in such cases. We present a case of a single fetal death in a monochorionic twin pregnancy with type III selective intrauterine growth restriction that involved low fractional shortening, high myocardial performance index, elevated pulsatility index in the middle cerebral artery and fetal ascites. After immediate intrauterine transfusion, each parameter improved promptly. The surviving baby grew up without cardiac and neurological complications. To the best of our knowledge, this is the first report on transient circulatory insufficiency and decreased cardiac function in the surviving fetus.
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Affiliation(s)
- Shigenori Iwagaki
- Department of Fetal Maternal Medicine, National Nagara Medical Center, Gifu, Japan
| | - Yuichiro Takahashi
- Department of Fetal Maternal Medicine and Obstetrics, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Rika Chiaki
- Department of Fetal Maternal Medicine, National Nagara Medical Center, Gifu, Japan
| | - Kazuhiko Asai
- Department of Fetal Maternal Medicine, National Nagara Medical Center, Gifu, Japan
| | - Masako Matsui
- Department of Fetal Maternal Medicine, National Nagara Medical Center, Gifu, Japan
| | - Daisuke Katsura
- Department of Fetal Maternal Medicine, National Nagara Medical Center, Gifu, Japan
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6
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Fitzgerald B. Histopathological examination of the placenta in twin pregnancies. APMIS 2018; 126:626-637. [DOI: 10.1111/apm.12829] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 01/30/2018] [Indexed: 11/26/2022]
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7
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Kawamura H, Ishii K, Yonetani N, Mabuchi A, Hayashi S, Mitsuda N. Significance of chorionicity on long-term outcome of low birthweight infants of <1500g in twin pregnancies. J Obstet Gynaecol Res 2015; 41:1185-92. [DOI: 10.1111/jog.12703] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 01/08/2015] [Accepted: 01/30/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Hiroshi Kawamura
- Department of Maternal Fetal Medicine; Osaka Medical Center and Research Institute for Maternal and Child Health; Osaka Japan
| | - Keisuke Ishii
- Department of Maternal Fetal Medicine; Osaka Medical Center and Research Institute for Maternal and Child Health; Osaka Japan
| | - Naoto Yonetani
- Department of Maternal Fetal Medicine; Osaka Medical Center and Research Institute for Maternal and Child Health; Osaka Japan
| | - Aki Mabuchi
- Department of Maternal Fetal Medicine; Osaka Medical Center and Research Institute for Maternal and Child Health; Osaka Japan
| | - Shusaku Hayashi
- Department of Maternal Fetal Medicine; Osaka Medical Center and Research Institute for Maternal and Child Health; Osaka Japan
| | - Nobuaki Mitsuda
- Department of Maternal Fetal Medicine; Osaka Medical Center and Research Institute for Maternal and Child Health; Osaka Japan
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Shek NWM, Hillman SC, Kilby MD. Single-twin demise: Pregnancy outcome. Best Pract Res Clin Obstet Gynaecol 2014; 28:249-63. [DOI: 10.1016/j.bpobgyn.2013.11.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 10/24/2013] [Accepted: 11/21/2013] [Indexed: 12/01/2022]
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Lewi L, Deprest J, Hecher K. The vascular anastomoses in monochorionic twin pregnancies and their clinical consequences. Am J Obstet Gynecol 2013; 208:19-30. [PMID: 23103301 DOI: 10.1016/j.ajog.2012.09.025] [Citation(s) in RCA: 160] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 09/10/2012] [Accepted: 09/21/2012] [Indexed: 11/18/2022]
Abstract
Monochorionic twin pregnancies are at increased risk of adverse outcome because of the vascular anastomoses that connect the 2 fetal circulation systems. The shared circulation is responsible for some unique complications in monochorionic twins, such as the twin-to-twin transfusion syndrome, the twin anemia polycythemia sequence, the twin reversed arterial perfusion sequence, and monoamniotic twinning. Another consequence of the shared circulation is that the well-being of one twin critically depends on that of the other. In this review, we will describe the technique of placental injection. Further, we will discuss the role of the vascular anastomoses in each of the complications described above and provide an update on their management.
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Gillissen A, Sueters M, van Lith J, Walther F, Lopriore E. Acute Hemorrhage in Monochorionic Twins with Ruptured Velamentous Vessels: Anemic Twin Resuscitated by Its Co-Twin through Placental Vascular Anastomoses? Fetal Diagn Ther 2013; 34:56-8. [DOI: 10.1159/000345649] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 11/05/2012] [Indexed: 11/19/2022]
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Hillman SC, Morris RK, Kilby MD. Single twin demise: consequence for survivors. Semin Fetal Neonatal Med 2010; 15:319-26. [PMID: 20584634 DOI: 10.1016/j.siny.2010.05.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Multiple pregnancies, the majority of which are twins, are at substantially higher risk of fetal morbidity and mortality when compared with singleton pregnancies. Single fetal demise occurs in up to 6.2% of all twin pregnancies. It may cause considerable risk for the co-twin including increased risk of fetal loss, premature delivery, neurovascular injury and end-organ damage. In this review we seek to summarise the most contemporary literature on the aetiology of single twin demise, the pathophysiology of injury to the surviving twin and the evidence for current management strategies.
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Affiliation(s)
- S C Hillman
- School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
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12
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13
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Perinatal outcome and neurological follow up of the cotwins in twin pregnancies complicated by single intrauterine death. Eur J Obstet Gynecol Reprod Biol 2009; 147:37-40. [DOI: 10.1016/j.ejogrb.2009.07.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2008] [Revised: 05/22/2009] [Accepted: 07/12/2009] [Indexed: 11/20/2022]
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14
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[Twin pregnancy with single fetal death: etiology, management and outcome]. ACTA ACUST UNITED AC 2009; 38:580-7. [PMID: 19833451 DOI: 10.1016/j.jgyn.2009.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2009] [Revised: 08/07/2009] [Accepted: 09/09/2009] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Intra-uterine fetal death (IUFD) of one twin is a relatively frequent complication of twin pregnancy. Prognosis of the surviving twin seems to be the main problem. Management is not consensual and suffers from the lack of guidelines. OBJECTIVES To report the main involved etiologies, assess the surviving co-twin outcome and discuss strategies of management. PATIENTS AND METHODS Retrospective study of 33 twin pregnancies complicated by single intrauterine fetal death after 26 weeks of gestation, admitted in the department "A" of obstetrics and gynecology of the Tunisian center of maternity and neonatalogy from January 2000 to October 2008. RESULTS Prevalence was 2.98%. Chorionicity was precised for 28 GG; 67.9% (n=19) were bichorionic (BC) and 32.1% (n=9) monochorionic (MC). The mean gestational age at the time of fetal death diagnosis was 31 weeks+2 days. Main involved pathologies in case of BC pregnancy were: intrauterine growth restriction (36.8%), pre-eclampsia (21%) and gestational diabetes (15.8%) and in case of MC pregnancy: twin-to-twin transfusion syndrome (44.4%). Prematurity rate was 85.2%. IUFD of the second twin occurred in one case and neonatal death in six cases. Tranfontanellar ultrasound on the seventh day of life found cerebral abnormalities in six liveborns. CONCLUSION Surviving co-twin prognosis was mainly compromised by prematurity and its consequences.
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Quarello E, Molho M, Ville Y. Incidence, mechanisms, and patterns of fetal cerebral lesions in twin-to-twin transfusion syndrome. J Matern Fetal Neonatal Med 2009; 20:589-97. [PMID: 17674276 DOI: 10.1080/14767050701449638] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To determine the incidence of fetal cerebral lesions and their characteristics in twin-to-twin transfusion syndrome (TTTS). DESIGN AND SETTING This was a retrospective analysis at a single center for the period 1999 to 2004 in which 299 cases of severe TTTS at 15-28 weeks of gestation were reviewed. METHODS Only cerebral injuries diagnosed during pregnancy or ischemic lesions diagnosed within the first week of life were considered in order to exclude those related to prematurity. We only included cases resulting in at least one survivor at one week after delivery, as well as fetuses that were terminated because of severe cerebral abnormalities. We excluded all fetuses delivered at <24 weeks of gestation that died prior to undergoing postnatal cranial ultrasonography. The main outcome measures were fetal cerebral lesions, intrauterine death, survival, and neonatal death. RESULTS Two hundred and ninety-nine pregnancies were evaluated. Three hundred and fifteen fetuses were reviewed. Cerebral abnormalities developed antenatally in 26/315 fetuses (8.25%). All lesions but one were diagnosed prenatally. Prenatal diagnosis of these lesions was achieved primarily by ultrasound (US) and magnetic resonance imaging (MRI), in 20/25 (80%) and in 5/25 (20%) fetuses, respectively. Cerebral abnormalities developed following primary laser coagulation in 12/222 (5.40%), following serial amnioreduction in 9/66 (13.63%), and following expectant management in 3/14 (21.4%) fetuses. Abnormalities developed after single intrauterine fetal death (IUFD) in 14 cases. CONCLUSIONS Cerebral morbidity in TTTS mainly occurs following vascular disruptive lesions. Both donors and recipients are at risk of developing either ischemic or hemorrhagic lesions. The risk of developing cerebral lesions in single survivors is significantly lower following laser treatment. Combined use of a targeted US and fetal MRI could detect most cerebral abnormalities antenatally. Timing of the triggering event is critical for planning serial US and MRI follow-up examinations.
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Affiliation(s)
- Edwin Quarello
- Department of Obstetrics and Gynecology, CHI Poissy St Germain-en-Laye, Université Paris-Ouest, Poissy, France
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Quarello E, Stirnemann J, Nassar M, Nasr B, Bernard JP, Leleu-Huard F, Ville Y. Outcome of anaemic monochorionic single survivors following early intrauterine rescue transfusion in cases of feto-fetal transfusion syndrome. BJOG 2008; 115:595-601. [DOI: 10.1111/j.1471-0528.2007.01659.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lemerle S, Le Vaillant C, Dubreil C, Boog G. Mise en évidence des anastomoses vasculaires par la vélocimétrie doppler dans les grossesses gémellaires monochoriales. Revue de la littérature à propos de trois cas. ACTA ACUST UNITED AC 2007; 36:777-85. [PMID: 17616263 DOI: 10.1016/j.jgyn.2007.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2006] [Revised: 02/14/2007] [Accepted: 05/18/2007] [Indexed: 11/28/2022]
Abstract
Three cases of intermittent absent end-diastolic and reversed end-diastolic flow velocity (A/REDV) are reported in the proximal umbilical artery of the growth-retarded twin in monochorionic twin pregnancies. This typical doppler velocimetric pattern has been related to arterio-arterial anastomoses in two cases of intra-uterine growth retardation and in one case of twin-twin transfusion syndrome. According to the literature, superficial arterio-arterial anastomoses may be detected by doppler colour velocimetry in 75 to 85% of cases, while identification of arteriovenous connections is more difficult to be documented in vivo (50% of cases in experienced hands). The role of superficial vascular anastomoses, either arterio-arterial or venovenous, and that of deep arteriovenous communications is now well documented in the main complications of monochorionic pregnancies, particularly for twin-twin transfusion syndrome, intrauterine growth retardation, intrauterine fetal death and acardiac twins.
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Affiliation(s)
- S Lemerle
- Service de gynécologie-obstétrique, hôpital Mère-Enfant, 38, boulevard Jean-Monnet, 44035 Nantes cedex 01, France
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18
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Ozcan T, Thornburg L, Mingione M, Pressman E. Use of middle cerebral artery peak systolic velocity and intrauterine transfusion for management of twin-twin transfusion and single fetal intrauterine demise. J Matern Fetal Neonatal Med 2006; 19:807-9. [PMID: 17190694 DOI: 10.1080/14767050601023533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Nakata M, Sumie M, Murata S, Miwa I, Kusaka E, Sugino N. A Case of Monochorionic Twin Pregnancy Complicated with Intrauterine Single Fetal Death with Successful Treatment of Intrauterine Blood Transfusion in the Surviving Fetus. Fetal Diagn Ther 2006; 22:7-9. [PMID: 17003547 DOI: 10.1159/000095834] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2005] [Accepted: 01/21/2006] [Indexed: 11/19/2022]
Abstract
We report a case of monochorionic twin pregnancy complicated with single fetal demise that received successful treatment of intrauterine transfusion for severe anemia of the surviving fetus. A single fetal demise occurred at 20 weeks of gestation and middle cerebral artery peak systolic velocity (MCA-PSV), a marker for fetal anemia, showed marked elevation in the surviving fetus. Fetal blood sampling was immediately done and severe fetal anemia (hemoglobin = 5.5 g/dl, hematocrit = 16.8%) was confirmed, and then intrauterine transfusion was performed. After transfusion, MCA-PSV rapidly decreased to the normal value and remained within normal range until delivery. A healthy 2,640 g male infant was delivered at 35 weeks of gestation without anemic status and no neurological problem was found at 1-year old. The present report supports that intrauterine rescue transfusion is a useful treatment to prevent the adverse outcome of surviving fetus in monochorionic twin pregnancy complicated with single fetal demise, and monitoring of MCA-PSV is also useful to assess anemic status of the surviving fetus.
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Affiliation(s)
- Masahiko Nakata
- Perinatal Care Center, Yamaguchi University Hospital, Ube, Japan.
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20
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Abstract
The epidemic of multiple pregnancy continues albeit in a different form with twin pregnancies predominating. Determination of chorionicity is the key to management and regular monitoring by ultrasound is a hallmark of quality care. All multiple pregnancies should be offered first trimester screening by nuchal translucency for aneuploidy. MC twins should be scanned at fortnightly intervals to allow complications such as twin-twin transfusion or IUGR to be detected and referral made to a fetal medicine centre. Maternal complications are common and vigilance is required for their detection. Although planned vaginal delivery can often be achieved, mothers must be prepared for the substantial risk of requiring a caesarean section as this currently occurs in the majority.
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Affiliation(s)
- Myles J O Taylor
- Peninsula Medical School, Universities of Exeter and Plymouth, Consultant Obstetrician and Gynaecologist, Subspecialist in Fetal and Maternal Medicine, Royal Devon and Exeter NHS Foundation Trust, UK.
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21
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Denbow ML, Talbert D, Fisk NM. Determinants of flow along arterio-arterial anastomoses in monochorionic placentae by dynamic computer modelling of chorionic plate vasculature. Prenat Diagn 2006; 26:433-42. [PMID: 16548009 DOI: 10.1002/pd.1432] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To investigate anatomical and physiological determinants of inter-fetal transfusion along arterio-arterial (AA) anastomoses in monochorionic placentae. METHODS A computer model of chorionic arterial vasculature was constructed in QuickBASIC using data collected from experimentation and the published literature. After validating the model, the influence of various physiological and anatomical variables on anastomotic flow rates was examined. RESULTS AA anastomotic flow rates were significantly related to changes in fetal mean arterial pressure (p < 0.0001) and heart rate (p < 0.0005). AA flow rates were also related to the imbalance in number of arterio-venous (AV) anastomoses, to placental territory share, and to the branch number of the AA anastomosis (AAAs) from the chorionic arterial tree. CONCLUSIONS Net blood flow and direction along AA anastomoses are influenced by fetal cardiac output, by the presence of compensatory AV anastomoses, and by the branch number of the chorionic arteries connected by the anastomosis. This study provides insight into the determinants of chronic transfusional imbalance as well as acute inter-fetal transfusion.
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Affiliation(s)
- Mark L Denbow
- Institute of Reproductive and Developmental Biology, Imperial College London, & Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Hammersmith Campus, Du Cane Road, London W12 ONN, UK.
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Abstract
The monochorionic placenta should be considered a developmental malformation and, as such, represents one of the most common birth defects. Great strides are being made to unravel the progression of nature's successful attempt at human cloning through fission. Critical to any strategy to reduce the perinatal morbidity and mortality associated with monochorionic placentas is early detection. Intense surveillance in at risk pregnancies will provide a better understanding of their natural progression, improve the prognosis with early intervention, and ultimately provide the key to prevent many of the complications unique to the monochorionic placenta.
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Affiliation(s)
- Thomas Trevett
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, CB#7516, 214 MacNider Building, Chapel Hill, NC 27599-7516, USA
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Galea P, Jain V, Fisk NM. Insights into the pathophysiology of twin–twin transfusion syndrome. Prenat Diagn 2005; 25:777-85. [PMID: 16170838 DOI: 10.1002/pd.1264] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Twin-twin transfusion syndrome (TTTS) is attributed to trans-anastomotic transfusion between twins. Anastomoses are ubiquitous in monochorionic (MC) placentae, yet TTTS develops in only 15%. Although ex vivo and in vivo studies fail to identify a unique anastomotic signature, TTTS placentae are typically associated with an imbalance in unidirectional arteriovenous anastomoses with absent bidirectional anastomoses. Doppler detection of an artery-artery anastomosis reduces the chance of TTTS, whereas, in those that develop the disease, it improves stage-independent survival. Selective laser is often curative, but an increasingly recognized risk of persistent or reverse TTTS may be attributable to atypical arteriovenous anastomoses not identifiable from the chorionic plate. Simple dysvolaemia fails to explain several phenotypic features, including haematological concordancy, recipient hypertension, and reversibly absent end diastolic flow in the donor. The renin-angiotensin system is upregulated in the donor and downregulated in the recipient's kidneys, while paradoxically raised renin levels in the recipient may contribute to raised afterload along with endothelin. Although research is limited in humans by therapy and the lack of a suitable experimental model, further studies of placental and vascular pathophysiology may not only refine current treatment modalities but may also, in addition, suggest further avenues for downstream management such as genetic predisposition testing or pharmacological intervention.
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Affiliation(s)
- Paula Galea
- Experimental Fetal Medicine Group, Institute of Reproductive and Developmental Biology, Imperial College London, UK.
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24
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Abstract
There is an increased risk of CP in multiple as compared with singleton pregnancies, and the higher the number of fetuses the greater is the prevalence of CP. Although LBW and preterm birth are the most significant risk factors for CP, the disadvantage of twins is apparent near term. Moreover, the excessive risk is not only the result of over-representation of multiples among premature babies, but seems to be associated with circumstances that are unique to the twinning process. The risk of CP should be acknowledged not only when a multiple pregnancy is diagnosed, but also when counseling infertility patients in whom iatrogenic multiple pregnancies are an actual risk.
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Affiliation(s)
- Isaac Blickstein
- Department of Obstetrics and Gynecology, Kaplan Medical Center, 76100 Rehovot, Israel.
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25
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Pasquini L, Wimalasundera RC, Fisk NM. Management of other complications specific to monochorionic twin pregnancies. Best Pract Res Clin Obstet Gynaecol 2004; 18:577-99. [PMID: 15279818 DOI: 10.1016/j.bpobgyn.2004.04.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Monochorionic (MC) twins have a 3-10-fold higher perinatal mortality and morbidity than dichorionic twins. This is largely attributable to their common vascular architecture and the high rate of discordant fetal growth, growth restriction and congenital abnormalities. In the event of a single intrauterine death (IUD), intertwin agonal transfusion results in up to a 38% risk of death and a 46% risk of neurological injury to the co-twin. This chapter addresses the management of complications unique to MC twins. The primary aim of management is to prevent single IUD or, if inevitable, prevent agonal transfusion occurring by vascular occlusive selective feticide. Older fetoscopic techniques have been replaced by the simpler ultrasound-guided techniques of interstitial laser and bipolar cord occlusion. Their application in twin reversed-arterial perfusion sequence has been associated with a 50% reduction of perinatal mortality in the pump twin. Moreover, prophylactic interstitial laser therapy in early pregnancy might obviate the technical and clinical difficulties in the presence of fetal decompensation in later pregnancy. Recent strategies to reduce the high perinatal mortality due to cord entanglement in antenatally diagnosed monoamniotic twins including medical amnioreduction and elective caesarean delivery at 32 weeks, are also discussed.
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Affiliation(s)
- L Pasquini
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Du Cane Road, Hammaersmith, W12 0HS London, UK.
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26
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Tan TYT, Taylor MJO, Wee LY, Vanderheyden T, Wimalasundera R, Fisk NM. Doppler for Artery–Artery Anastomosis and Stage-Independent Survival in Twin–Twin Transfusion. Obstet Gynecol 2004; 103:1174-80. [PMID: 15172849 DOI: 10.1097/01.aog.0000127881.34144.d8] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Treatment selection in twin-twin transfusion syndrome is increasingly determined by disease severity. We investigated whether detection of arterio-arterial anastomoses predicts perinatal survival. METHODS An artery-artery anastomosis was sought by Doppler and disease stage was determined in 105 cases of twin-twin transfusion syndrome at presentation, first treatment, and worst stage. Outcome measures were perinatal, double, and any (1 or more babies) survival rates. RESULTS After exclusion of 10 noninformative pregnancies, perinatal, double, and any survival rates were 61%, 44%, and 77%, respectively. When an anastomosis was detected at each of the 3 time points, perinatal and double survival rates were higher than when one was not (at first treatment, perinatal survival 83% versus 53%, respectively, P =.003; double survival 78% versus 33%, P <.001). Perinatal and double survival (P < or =.01) were poorer with more advanced stage, but any survival rates were not influenced by stage or anastomosis detection. Multiple logistic regression demonstrated that anastomosis detection at treatment increased the chance of perinatal (odds ratio [OR] 5.1, 95% confidence interval [CI] 1.6, 15.9) and double survival (OR 19.3, 95% CI 2.7, 138), independently of stage. For stages I-III at treatment, anastomosis detection predicted better perinatal (100% versus 63%, 100% versus 59%, and 83% versus 44%, respectively) and double survival rates (100% versus 52%, 100% versus 46%, and 78% versus 26%). Stage III, with anastomoses detected, had better perinatal (83% versus 63%) and double survival (78% versus 52%) than did stage I without detection. CONCLUSION Antenatal detection of artery-to-artery anastomosis predicts higher perinatal and double survival in twin-twin transfusion syndrome, independently of disease stage. LEVEL OF EVIDENCE II-3
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Affiliation(s)
- Tony Y T Tan
- Institute of Reproductive and Developmental Biology, Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0NN, United Kingdom
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27
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Ralston SJ, Craigo SD. Ultrasound-guided procedures for prenatal diagnosis and therapy. Obstet Gynecol Clin North Am 2004; 31:101-23. [PMID: 15062449 DOI: 10.1016/s0889-8545(03)00124-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Ultrasonography has expanded the capabilities of perinatologists to examine,test, and treat the fetus. Amniocentesis and CVS are safe and widely available procedures, which can be used to diagnose a multitude of abnormalities through karyotype analysis and molecular studies. CVS allows earlier diagnosis, but both procedures can provide highly accurate results in the first half of pregnancy. Cordocentesis has fewer indications, but allows direct laboratory testing of fetal blood. Fetocentesis and fetal biopsy are reserved for limited indications, but can play a crucial role in the diagnosis of some conditions, which cannot be assessed less invasively. Fetal transfusion is an important tool in the treatment of isoimmunization, some other forms of fetal anemia, and alloimmune thrombocytopenia. Amnioreduction is a commonly used procedure for the treatment of polyhydramnios and TTTS. Multifetal reduction and selective termination offer previously unavailable options to patients carrying multiple gestations. Fetal shunts can reduce perinatal morbidity and mortality in cases of bladder outlet obstruction and hydrothorax. The limited experience with cord ligation procedures and balloon valvuloplasty suggests these relatively new procedures may serve a greater role in the future as techniques are improved. By providing guidance for all of these procedures, real-time ultrasonography has revolutionized prenatal diagnosis and therapy; it will continue to be a crucial component in evaluating and treating complicated pregnancies.
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Affiliation(s)
- Steven J Ralston
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tufts University School of Medicine, Tufts-New England Medical Center, 750 Washington Street, Box 360, Boston, MA 02111, USA
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28
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Quintero RA, Martínez JM, Bermúdez C, López J, Becerra C. Fetoscopic demonstration of perimortem feto-fetal hemorrhage in twin-twin transfusion syndrome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2002; 20:638-639. [PMID: 12493060 DOI: 10.1046/j.1469-0705.2002.00859.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Affiliation(s)
- R A Quintero
- Florida Institute for Fetal Diagnosis and Therapy, St Joseph's Women's Hospital, Tampa, USA.
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29
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Senat MV, Bernard JP, Loizeau S, Ville Y. Management of single fetal death in twin-to-twin transfusion syndrome: a role for fetal blood sampling. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2002; 20:360-363. [PMID: 12383318 DOI: 10.1046/j.1469-0705.2002.00815.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVE Intrauterine death of one twin in monochorionic pregnancies is associated with an increased mortality and morbidity of the cotwin. This is likely to occur as a consequence of acute hemodynamic changes due to feto-fetal hemorrhage at the time of death of the cotwin. We assessed the role of fetal blood sampling and intrauterine transfusion to rescue the survivor. MATERIALS AND METHODS We managed 12 cases of single intrauterine death at between 17 and 26 weeks' gestation in monochorionic twins complicated by twin-to-twin transfusion syndrome (TTTS). All these cases had been treated either by laser therapy or by serial amniodrainage. When the demise of one twin occurred, ultrasound-guided fetal blood sampling was performed in the surviving twin using a 20-gauge needle within 24 h of death. Intrauterine transfusion was performed at the same time in cases where the survivor was anemic. All survivors were assessed in the neonatal period and at 1 year of age. RESULTS Six of the 12 surviving fetuses were found to be anemic and underwent intrauterine transfusion. All fetuses survived the procedure. Four of these fetuses had normal neurological development at 1 year of age. Periventricular leukomalacia developed in one case and the patient underwent termination of pregnancy at 34 weeks. In one case delivery occurred at 34 weeks' gestation and the baby developed periventricular leukomalacia at 1 month of age. In all six non-anemic fetuses pediatric examination was normal at birth and at 1 year of age. CONCLUSION Intrauterine death of one monochorionic twin in TTTS puts the survivor at high risk of intrauterine death or of developing ischemic/hypoxic lesions. Our results suggest that fetal blood sampling is a useful diagnostic tool to identify those fetuses that are not anemic and hence unlikely to be at risk of developing a cerebral lesion.
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Affiliation(s)
- M-V Senat
- Department of Obstetrics and Gynecology, Paris-Ouest University, CHI Poissy-St-Germain, France
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30
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Current Awareness. Prenat Diagn 2001. [DOI: 10.1002/pd.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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