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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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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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Alshanafey S, Al-Nemer M, Tulbah M, Khan RM, Sahan NA, Mugbel MA, Al-Hazzani F, Almutairi G, Kurdi W. Management of twin reversed arterial perfusion sequence: eight cases over 13 years. Ann Saudi Med 2023; 43:199-203. [PMID: 37554025 DOI: 10.5144/0256-4947.2023.199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Twin reversed arterial perfusion (TRAP) sequence is a rare condition that affects primarily monozygotic monochorionic twin pregnancies in which a normal twin acts as a pump (donor) for an acardiac recipient (perfuse) twin. OBJECTIVE We report our experience over the last 13 years at a tertiary health care center. DESIGN Descriptive, retrospective case series SETTING: Tertiary health care center PATIENTS AND METHODS: All TRAP cases managed between the years 2009 and 2022 at our Fetal Diagnosis and Therapy Center were included. Data recorded included demographic and clinical information which was used to generate descriptive data. Patients were managed by a multidisciplinary team with variable interventions. MAIN OUTCOME MEASURE Survival of normal twin SAMPLE SIZE: Eight RESULTS: Eight pregnant women with TRAP syndrome were managed at our center during that period. One was monozygotic monochorionic and the others were monochorionic diamniotic. Median maternal age at presentation was 27 years and median gestational age at diagnosis was 23 weeks. All were diagnosed with ultrasound (US) imaging. Three were managed with bipolar ligation of the cord of the acardiac twin under general anesthesia, one US-guided (single port) and 2 fetoscopic (2 ports) with a median operative time of 39 minutes. The last five cases were managed with US-guided radiofrequency ablation (RFA) under local anesthesia, one needed 2 sessions, 1 week apart. The median duration of the RFA procedure was 23 minutes. There were no complications and all had viable normal babies born at a median of 32 weeks of gestation (6 C-section, 2 spontaneous membrane rupture). CONCLUSIONS Acardiac twin cord ligation and RFA are feasible and safe options with excellent outcome for TRAP syndrome. RFA may be preferable owing to its less invasiveness under local anesthesia. LIMITATIONS None, given the rarity of the disease and the study design. CONFLICT OF INTEREST None.
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Affiliation(s)
- Saud Alshanafey
- From the Department of Surgery, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Maha Al-Nemer
- From the Department of Obstetrics and Gynecology Perinatology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Maha Tulbah
- From the Department of Obstetrics and Gynecology Perinatology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Rubina Ma Khan
- From the Department of Obstetrics and Gynecology Perinatology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Nada Al Sahan
- From the Department of Obstetrics and Gynecology Perinatology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Maisoon Al Mugbel
- From the Department of Obstetrics and Gynecology Perinatology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Fahad Al-Hazzani
- From the Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Gawaher Almutairi
- From the Department of Fetal Therapy, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Wesam Kurdi
- From the Department of Obstetrics and Gynecology Perinatology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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Vitucci A, Fratelli N, Fichera A, Sartori E, Prefumo F. Timing of intra-fetal laser therapy for twin reversed arterial perfusion (TRAP) sequence: Retrospective series and systematic review and meta-analysis. Int J Gynaecol Obstet 2022; 159:833-840. [PMID: 35435256 PMCID: PMC9790320 DOI: 10.1002/ijgo.14221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/24/2022] [Accepted: 04/11/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To estimate the neonatal survival rate after intra-fetal laser (IFL) treatment for twin reversed arterial perfusion (TRAP) sequence, and to investigate the effect of gestational age at the time of procedure. METHODS Retrospective cohort study of TRAP sequences followed at our institution from 2013-2020. Systematic review and meta-analysis of the neonatal survival rate after IFL was conducted. Both diamniotic and monoamniotic monochorionic pregnancies were included. A subgroup analysis to compare outcomes according to gestational age at procedure (<16+0 weeks or ≥16+0 weeks) was planned. RESULTS Thirteen pregnancies were followed at our center and seven were treated with IFL: the survival rate was 57%. Ten studies published between 2008 and 2020 for a total of 156 cases were included in the meta-analysis. The overall neonatal survival after IFL was 79% (95% CI 0.72-0.86, I2 22%). A random-effects model comparing neonatal survival for IFL performed <16+0 weeks versus ≥16+0 weeks showed no significant difference between the two groups (OR = 0.93; 95% CI 0.37-2.33). CONCLUSION IFL is a safe and minimally invasive technique for the treatment of TRAP sequence, with a survival rate of 79%. Gestational age at treatment (before or after 16 weeks) does not seem to affect neonatal survival rate.
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Affiliation(s)
- Annachiara Vitucci
- Division of Obstetrics and GynecologyASST Spedali Civili and Department of Clinical and Experimental SciencesUniversity of BresciaBresciaItaly
| | - Nicola Fratelli
- Division of Obstetrics and GynecologyASST Spedali Civili and Department of Clinical and Experimental SciencesUniversity of BresciaBresciaItaly
| | - Anna Fichera
- Division of Obstetrics and GynecologyASST Spedali Civili and Department of Clinical and Experimental SciencesUniversity of BresciaBresciaItaly
| | - Enrico Sartori
- Division of Obstetrics and GynecologyASST Spedali Civili and Department of Clinical and Experimental SciencesUniversity of BresciaBresciaItaly
| | - Federico Prefumo
- Division of Obstetrics and GynecologyASST Spedali Civili and Department of Clinical and Experimental SciencesUniversity of BresciaBresciaItaly
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Weber EC, Recker F, Gottschalk I, Strizek B, Geipel A, Gembruch U, Berg C. Outcome of TRAP Sequence Treated in the First Trimester - A Ten-Year Single-Center Experience. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2022; 43:614-618. [PMID: 34187078 DOI: 10.1055/a-1526-1775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
PURPOSE To evaluate the outcome of first trimester intervention by intrafetal laser (IFL) in pregnancies complicated by twin reversed arterial perfusion (TRAP). MATERIALS AND METHODS For a 10-year study period, all patients with TRAP diagnosed < 14.0 weeks of gestation were retrospectively analyzed for intrauterine course and outcome. Monoamniotic pregnancies were excluded. Patients were offered either intervention by IFL in the first trimester, expectant management, or termination of pregnancy (TOP). Adverse outcome was defined as either intrauterine death (IUD), neonatal death, or preterm birth. RESULTS In 45 cases TRAP was diagnosed. 17 monoamniotics were excluded. The cohort was divided into two groups according to management. Group A: 24 cases underwent IFL and group B: 4 cases were managed expectantly. No patient opted for TOP. In group A, 70.8 % of pump twins were born alive, including one preterm delivery, and 29.2 % died within four days after the intervention. All 4 expectantly managed cases in group B had an adverse outcome (1 preterm delivery, 3 IUDs < 15.0 weeks). There were no neonatal deaths. In cases treated by IFL, a comparison of survivors and non-survivors identified no significant differences in gestational age at IFL or any of the assessed biometrical and functional parameters. There was a trend towards better outcome in the second half of the study period. CONCLUSION IFL in first trimester TRAP sequence is technically feasible but is associated with significant mortality, albeit less than previously reported. No risk stratification is possible using the investigated parameters. However, there seems to be a learning curve.
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Affiliation(s)
- Eva Christin Weber
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Germany
| | - Florian Recker
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Germany
| | - Ingo Gottschalk
- Department of Prenatal Medicine, University Hospital Cologne, Köln, Germany
| | - Brigitte Strizek
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Germany
| | - Annegret Geipel
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Germany
| | - Ulrich Gembruch
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Germany
| | - Christoph Berg
- Department of Obstetrics and Prenatal Medicine, University Hospital Bonn, Germany
- Department of Prenatal Medicine, University Hospital Cologne, Köln, Germany
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Twin Reversed Arterial Perfusion Sequence: Prenatal Diagnosis and Treatment. MATERNAL-FETAL MEDICINE 2022. [DOI: 10.1097/fm9.0000000000000172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] 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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Tang Y, Zeng Y, Yang T, Yang P, Bao S, He M, Ying J. Ultrasound assessment of twin reversed arterial perfusion sequence for the prediction of adverse pregnancy outcomes in the first trimester. J Evid Based Med 2022; 15:230-235. [PMID: 35934776 DOI: 10.1111/jebm.12488] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 07/25/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To investigate twin reversed arterial perfusion (TRAP) sequence for the prediction of TRAP-related adverse pregnancy outcomes at the gestational age of 11-14 weeks. METHODS Pregnant women in the first trimester diagnosed with TRAP were recruited at West China Second University Hospital from January 2015 to June 2018. Systematic screening for the pump twin's crown-rump length (CRL) and acardiac twin's upper pole-rump length (URL) was conducted using ultrasonic detection. The (CRL - URL)/CRL and URL/CRL ratios were used to assess the pregnancy outcomes for the pump twin. Twenty-one pregnant women aged 21-39 years with a gestation of 11-14 weeks were recruited. RESULTS TRAP was diagnosed on average (± standard deviation (SD)) at pregnancy week 13.1 ± 0.18. The pump twins' mean (± SD) CRL was 6.65 ± 1.1 cm. The incidence of intrauterine death for the pump twins was 19.0% (n = 4), the miscarriage rate was 14.3% (n = 3), and the live birth rate was 66.7% (n = 14). The (CRL - URL)/CRL ratios between the nonsurvival (intrauterine death and miscarriage) and survival groups significantly differed (0.33 ± 0.08 vs. 0.58 ± 0.08, p < 0.05). Similarly, the URL/CRL ratios between the nonsurvival and survival groups significantly differed (0.67 ± 0.08 vs. 0.42 ± 0.08, p < 0.05). CONCLUSION The (CRL - URL)/CRL and URL/CRL ratios were valuable indicators for determining pregnancy outcomes of pump twins with TRAP at an early gestational age.
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Affiliation(s)
- Ying Tang
- Department of Ultrasonography, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Yan Zeng
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Taizhu Yang
- Department of Ultrasonography, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Pan Yang
- Department of Ultrasonography, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Shan Bao
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Min He
- Department of Ultrasonography, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
| | - Junjie Ying
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, China
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, China
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Dhanju G, Breddam A. Twin reversed arterial perfusion (TRAP) sequence: A case report and a brief literature review. Radiol Case Rep 2022; 17:1682-1691. [PMID: 35342490 PMCID: PMC8942792 DOI: 10.1016/j.radcr.2022.02.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 02/19/2022] [Indexed: 11/24/2022] Open
Abstract
Twin reversed arterial perfusion (TRAP) sequence is rare in monochorionic twin pregnancies. TRAP sequence is distinct from other multifetal pregnancies in that one of the twins has normal anatomy while the other twin has a varied amount of characteristic abnormal features. In the literature, mortality is reported 100% in the abnormal twin. We report 1 case of TRAP sequence at our institution in which the diagnosis of TRAP sequence was missed in the first trimester at another hospital. The patient, a 33-year-old G1P0A0, did not have any follow-up after her first scan until the routine second-trimester ultrasound at our institution. Both the radiologist and the sonographer did not appreciate the differential diagnosis of TRAP sequence in their clinical decision-making. The TRAP diagnosis was established after the ultrasound performed at the fetal assessment unit in our hospital. Radiofrequency ablation (RFA) procedure was performed to give the normal twin a chance to survive, but unfortunately, the prognosis was poor in this case. We conclude that diagnosing a TRAP sequence is very important early in the pregnancy for a positive outcome in the normal twin. A robust collaboration among radiologists and obstetricians is vital for the best outcome of the normal twin.
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Zhang L, Liu H, Huang S, Tong C, Wang Z, Qi H, Baker PN, Kilby MD. Alterations in Fetal Doppler Parameters Before and Twenty-Four Hours After Radiofrequency Ablation for Twin Reversed Arterial Perfusion Sequence. Front Med (Lausanne) 2022; 9:802666. [PMID: 35492315 PMCID: PMC9046669 DOI: 10.3389/fmed.2022.802666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 03/07/2022] [Indexed: 11/22/2022] Open
Abstract
Objective To evaluate alterations in the fetal Doppler parameters of pump fetuses before and 24 h after radiofrequency ablation surgery for twin reversed arterial perfusion sequence (TRAPs). Methods This is a retrospective study of 28 pump fetuses in TRAPs and 28 normal control twins between 2016 and 2021. The fetal Doppler parameters, including the umbilical artery pulsatility index (UA-PI), middle cerebral artery peak systolic velocity (MCA-PSV), middle cerebral artery pulsatility index (MCA-PI), and cerebroplacental ratio (CPR), of the controls, and pump fetuses before and 24 h after surgery were compared. Results An increasing trend and a further increase in the MCA-PSV, MCA-PI, MCA-PSV Z score, and MCA-PI Z score after surgery were observed in pump fetuses with gestational age (GA) ≥20 weeks; however, such changes were not observed in those with a GA of <20 weeks. The UA-PI and CPR before and after surgery were not different between control and pump fetuses, whether the GA was ≥20 or <20 weeks. Conclusion In the middle second trimester, the pump fetus might suffer from high cardiac output rather than hypoxemia before surgery and congestive heart failure, or hemodilutional anemia after surgery. This may provide some theoretical evidence in favor of early intervention, rather than waiting for a more advanced GA, to avoid unnecessary hemodynamic alterations.
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Affiliation(s)
- Lan Zhang
- State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Fetal Medicine Unit, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- International Collaborative Joint Laboratory of Reproduction and Development of Ministry of Education P.R.C., Chongqing Medical University, Chongqing, China
| | - Hongli Liu
- State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Fetal Medicine Unit, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- International Collaborative Joint Laboratory of Reproduction and Development of Ministry of Education P.R.C., Chongqing Medical University, Chongqing, China
| | - Shuai Huang
- State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Fetal Medicine Unit, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- International Collaborative Joint Laboratory of Reproduction and Development of Ministry of Education P.R.C., Chongqing Medical University, Chongqing, China
| | - Chao Tong
- State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- International Collaborative Joint Laboratory of Reproduction and Development of Ministry of Education P.R.C., Chongqing Medical University, Chongqing, China
- *Correspondence: Chao Tong,
| | - Zhigang Wang
- Institute of Ultrasound Imaging, Department of Ultrasound, Second Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Ultrasound Molecular Imaging, Chongqing, China
- Zhigang Wang,
| | - Hongbo Qi
- State Key Laboratory of Maternal and Fetal Medicine of Chongqing Municipality, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Fetal Medicine Unit, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- International Collaborative Joint Laboratory of Reproduction and Development of Ministry of Education P.R.C., Chongqing Medical University, Chongqing, China
- Hongbo Qi,
| | - Philip N. Baker
- College of Life Sciences, University of Leicester, Leicester, United Kingdom
| | - Mark D. Kilby
- Institute of Metabolism and System Research, University of Birmingham, Birmingham, United Kingdom
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11
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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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12
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Aldiansyah D, Lubis MP, Handayani D, Asroel EM, Barus MNG, Lubis BM. Twin reversed arterial perfusion sequence managed by bipolar cord coagulation and amniopatch: Case report. Int J Surg Case Rep 2022; 93:106893. [PMID: 35279523 PMCID: PMC8924629 DOI: 10.1016/j.ijscr.2022.106893] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/24/2022] [Accepted: 02/27/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction and importance Twin Reversed Arterial Perfusion (TRAP) Sequence is a rare condition that occurs in monochorionic twin pregnancies, resulting in the coexistence of a normal “pump” twin and an acardiac twin. Indonesia is implementing fetal therapy centers that are starting to treat fetal cases such as TRAP Sequence. Case presentation An 18 years old pregnant woman with monochorionic diamniotic pregnancy was detected by ultrasonographic examination. A live fetus with normal fetal heart rate estimated fetal weight was 661 g, and consistent with 25 w gestational age. Additionally, an acardiac twin with polyhydramnios and EFW of 1829 g. Bipolar cord coagulation, amniopatch, and amnioinfusion were performed. The patient's condition was stable and managed closely. Clinical discussion This is the first procedure reported in Indonesia for TRAP sequence case. It reduces cardiac strain on the pump twin and increases the chance of survival. Conclusion The patient was diagnosed with TRAP Sequence and bipolar cord coagulation to interrupt blood supply to the non-viable twin, amniopatch with autologous platelet concentrate followed by cryoprecipitate amnioinfusion were reported for the first time in Indonesia. The first case of bipolar cord coagulation and amniopatch in the TRAP sequence was reported in Indonesia. The first case report in Indonesia informs the success in the management of TRAP Sequence. Increase the survival of infant
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Affiliation(s)
- Dudy Aldiansyah
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Sumatera Utara, Medan, 20155 Indonesia; Fetal Therapy Unit, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, H. Adam Malik General Hospital, Medan, Sumatera Utara, 20136 Indonesia.
| | - Muara P Lubis
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Sumatera Utara, Medan, 20155 Indonesia; Fetal Therapy Unit, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, H. Adam Malik General Hospital, Medan, Sumatera Utara, 20136 Indonesia
| | - Desy Handayani
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Sumatera Utara, Medan, 20155 Indonesia
| | - Edwin M Asroel
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Sumatera Utara, Medan, 20155 Indonesia; Fetal Therapy Unit, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, H. Adam Malik General Hospital, Medan, Sumatera Utara, 20136 Indonesia
| | - Melvin N G Barus
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Sumatera Utara, Medan, 20155 Indonesia; Fetal Therapy Unit, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, H. Adam Malik General Hospital, Medan, Sumatera Utara, 20136 Indonesia
| | - Bugis Mardina Lubis
- Department of Pediatric, Faculty of Medicine, Universitas Sumatera Utara, Medan, 20155 Indonesia; Division of Neonatology, Department of Pediatric, H. Adam Malik General Hospital, Medan, Sumatera Utara, 20136 Indonesia
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13
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Li N, Sun J, Wang J, Jian W, Lu J, Miao Y, Li Y, Chen F, Chen D, Ye X, Chen M. Selective termination of the fetus in multiple pregnancies using ultrasound-guided radiofrequency ablation. BMC Pregnancy Childbirth 2021; 21:821. [PMID: 34893028 PMCID: PMC8662893 DOI: 10.1186/s12884-021-04285-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 11/23/2021] [Indexed: 12/02/2022] Open
Abstract
Background To evaluate the perinatal outcomes in women with selective termination using ultrasound-guided radiofrequency ablation (RFA). Methods Complicated monochorionic (MC) twin pregnancies and multiple pregnancies with an indication for selective termination by ultrasound-guided coagulation of the umbilical cord with RFA under local anesthesia between July 2013 and Jan 2020 were reviewed. We analyzed the indications, gestational age at the time of the procedure, cycles of RFA, duration of the procedure, and perinatal outcome. Results Three hundred and thirteen patients were treated during this period. Seven of whom were lost of follow-up. The remaining 306 cases, including 266 pairs of monochorionic diamniotic (MCDA) twins (86.93%), two pairs of monoamniotic twins (0.65%), 30 dichorionic triamniotic (DCTA) triplets (1%), and three monochorionic triamniotic (MCTA) triplets (0.98%), were analyzed. Indications included twin-to-twin transfusion syndrome (TTTS) (n = 91), selective fetal growth restriction (sFGR) (n = 83), severe discordant structural malformation (n = 78), multifetal pregnancy reduction (MFPR) (n = 78), twin reverse arterial perfusion sequence (TRAPS) (n = 19), and twin anemia-polycythemia sequence (TAPS) (n = 3). Upon comparison of RFA performed before and after 20 weeks, the co-twin loss rate (20.9% vs. 21.5%), the incidence of preterm premature rupture of membranes (PPROM) within 24 h (1.5% vs. 1.2%), and the median gestational age at delivery [35.93 (28–38) weeks vs. 36 (28.54–38.14) weeks] were similar (p > 0.05). Conclusions RFA is a reasonable option when indicated in multiple pregnancies and complicated monochorionic pregnancies. In our experience, the overall survival rate was 78.76% with RFA in selective feticide, and early treatment increases the likelihood of survival for the remaining fetus because the fetal loss rate is similar before and after 20 weeks.
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Affiliation(s)
- Nan Li
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Jimei Sun
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Jiayan Wang
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Wei Jian
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Jing Lu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Yonghui Miao
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Yufan Li
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Fei Chen
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Dunjin Chen
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Xiaoqing Ye
- Department of Ultrasound, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Min Chen
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China.
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14
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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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15
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Herrera TT, Rueda K, Espinosa H, Britton GB. Intestinal volvulus in the pump twin of a twin reversed arterial perfusion (TRAP) sequence after laser therapy at 18 weeks: a case report. J Med Case Rep 2020; 14:123. [PMID: 32767998 PMCID: PMC7414987 DOI: 10.1186/s13256-020-02444-3] [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: 11/28/2019] [Accepted: 06/30/2020] [Indexed: 12/05/2022] Open
Abstract
Background Twin reversed arterial perfusion sequence is a rare and potentially lethal condition affecting approximately 1% of monochorionic twin pregnancies and 1 in 35,000 pregnancies overall. An apparently normal (pump) twin perfuses its severely malformed cotwin with deoxygenated blood via retrograde flow in direct arterioarterial anastomoses between the umbilical arteries of each twin. Fetal intestinal volvulus is a rare condition usually manifesting after birth. We report a unique case of twin reversed arterial perfusion sequence in association with intestinal volvulus in the surviving pump twin. Case presentation A 32-year-old Hispanic primigravida was referred to our clinic after a fetoscopy procedure of laser photocoagulation of anastomoses at 18 weeks of gestation. Follow up scans in the ex-pump twin revealed dilated bowel loops and a typical “whirlpool sign” at 26 weeks of gestation, and intrauterine intestinal volvulus was suspected. At 29 weeks of gestation, preterm premature rupture of membranes occurred, and an emergency cesarean section was performed. The newborn was diagnosed in the early neonatal period with intestinal perforation. The diagnosis was postnatally confirmed by surgery and histopathology. Conclusions The type of fetal intervention and late gestational age of the procedure increase the risk of complications. This case alerts health providers to be vigilant in the follow-up of patients with complicated monochorionic pregnancies.
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Affiliation(s)
- Tania T Herrera
- Department of Obstetrics and Gynecology, Pacífica Salud, Panamá, Panamá. .,Instituto de Investigaciones Científicas y Servicios de Alta Tecnología (INDICASAT AIP), Ciudad del Saber, Panamá, Panamá.
| | - Katia Rueda
- Department of Pediatrics, Pacífica Salud, Panamá, Panamá
| | - Honorina Espinosa
- Division of Pediatrics, Hospital del Niño, Panamá, Panama.,Division of Pediatric Surgery, Hospital del Niño, Panamá, Panama
| | - Gabrielle B Britton
- Instituto de Investigaciones Científicas y Servicios de Alta Tecnología (INDICASAT AIP), Ciudad del Saber, Panamá, Panamá
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16
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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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17
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Shettikeri A, Acharya V, V S, Sahana R, Radhakrishnan P. Outcome of Pregnancies Diagnosed with TRAP Sequence Prenatally: A Single-Centre Experience. Fetal Diagn Ther 2019; 47:301-306. [PMID: 31770756 DOI: 10.1159/000503389] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 09/15/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Twin reversed arterial perfusion (TRAP) sequence is a phenomenon seen in 1-3% of monochorionic twin pregnancies, where the acardiac fetus is found to have multiple anomalies. The normal pump twin maintains its own perfusion in addition to that of its acardiac co-twin. As a result, if the acardiac twin increases in size, the burden on the pump twin is increased, leading to cardiac failure, hydrops fetalis, polyhydramnios, premature delivery, and perinatal death. The outcome of pregnancy is largely dependent on the growth of the acardiac twin. In view of high perinatal loss, surgical techniques to interrupt the blood flow to the acardiac twin have been evaluated. METHODS We evaluated interstitial laser therapy, which is the main mode of therapy in our unit, of TRAP pregnancies referred over a 5-year period. Interstitial laser was offered if the blood flow in the acardiac twin was found to be persistent at 2 consecutive examinations or if there were cardiac or hydropic changes in the pump twin at the first examination. RESULTS A total of 18 cases of TRAP were referred during this period and all were counselled regarding fetal therapy if the situation were to deteriorate; 5 couples (27.7%) opted for termination of pregnancy; of the remaining 13, 7 (53.8%) agreed to perform intervention following confirmation of a normal karyotype. Six (85.7%) and 1 (14.3%) lasers were performed in the second and third trimesters, respectively; all 7 had a normal outcome of the pump twin. There were 6/13 (46.2%) in the expectant group who continued the pregnancy with no intervention, with 2 term live births (33.3%). CONCLUSIONS Our study confirms that there is a high risk of spontaneous loss in untreated pregnancies with TRAP, primarily due to polyhydramnios and fetal hydrops. In the pregnancies that underwent interstitial laser, there was a more favourable outcome. Interstitial laser is minimally invasive, safe, and feasible in experienced hands.
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Affiliation(s)
- Anitha Shettikeri
- Department of Fetal Medicine, Bangalore Fetal Medicine Centre, Bangalore, India
| | - Veena Acharya
- Department of Fetal Medicine, Bangalore Fetal Medicine Centre, Bangalore, India
| | - Shailaja V
- Department of Fetal Medicine, Bangalore Fetal Medicine Centre, Bangalore, India
| | - Reeth Sahana
- Department of Fetal Medicine, Bangalore Fetal Medicine Centre, Bangalore, India
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18
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Seo K, Ichizuka K, Okai T, Dohi S, Nakamura M, Hasegawa J, Matsuoka R, Yoshizawa S, Umemura SI, Nagatsuka M, Sekizawa A. Treatment of twin-reversed arterial perfusion sequence using high-intensity focused ultrasound. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:128-134. [PMID: 30136326 DOI: 10.1002/uog.20101] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 07/31/2018] [Accepted: 08/10/2018] [Indexed: 06/08/2023]
Abstract
We describe our experience of high-intensity focused ultrasound (HIFU) for fetal therapy in twin-reversed arterial perfusion (TRAP) sequence. Six pregnant women underwent HIFU therapy, five before 16 weeks and one at 26 weeks. Two types of HIFU system were used: the first-generation system, which comprised a biaxial transducer and continuous exposure pattern, and the second-generation system, which comprised a coaxial transducer and sequential exposure pattern. The first-generation apparatus was used in four cases and the second-generation apparatus was used in two. In three cases, occlusion of the blood vessels mediating flow to the acardiac twin was achieved by HIFU. Two cases experienced intrauterine fetal death despite vessel occlusion. The total survival rate of pump fetuses 2 years after HIFU was 67% and the efficiency rate (the proportion of cases with occlusion or reduced blood flow on ultrasound after HIFU) was 83%. After more than 2 years of follow-up, the surviving infants had no severe clinical complications and no postnatal developmental problems. There was no significant difference in survival rate compared with TRAP cases managed expectantly. Given that complete occlusion of the blood vessels was not achieved in half of the cases, we could not show that HIFU therapy is superior to other treatments. However, HIFU can reduce the cardiac load of the pump fetus and, as it does not require uterine puncture for fetal therapy, there were no fatal complications, such as bleeding, rupture of membranes or infection. Thus, HIFU therapy may represent a less-invasive treatment for TRAP sequence in early pregnancy. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- K Seo
- Showa University, School of Medicine, Department of Obstetrics and Gynecology, Tokyo, Japan
| | - K Ichizuka
- Showa University, School of Medicine, Department of Obstetrics and Gynecology, Tokyo, Japan
| | - T Okai
- Showa University, School of Medicine, Department of Obstetrics and Gynecology, Tokyo, Japan
| | - S Dohi
- Showa University, School of Medicine, Department of Obstetrics and Gynecology, Tokyo, Japan
| | - M Nakamura
- Showa University, School of Medicine, Department of Obstetrics and Gynecology, Tokyo, Japan
| | - J Hasegawa
- St Marianna University, School of Medicine, Department of Obstetrics and Gynecology, Kanagawa, Japan
| | - R Matsuoka
- Showa University, School of Medicine, Department of Obstetrics and Gynecology, Tokyo, Japan
| | - S Yoshizawa
- Tohoku University, Graduate School of Biomedical Engineering, Miyagi, Japan
| | - S-I Umemura
- Tohoku University, Graduate School of Biomedical Engineering, Miyagi, Japan
| | - M Nagatsuka
- Showa University, School of Medicine, Department of Obstetrics and Gynecology, Tokyo, Japan
| | - A Sekizawa
- Showa University, School of Medicine, Department of Obstetrics and Gynecology, Tokyo, Japan
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19
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Piorkowska K, Waspe AC, Wang T, Mougenot C, Ryan G, Drake JM, Gerstle JT. Noninvasive ablation of rabbit fetal and placental tissue targets in utero using magnetic resonance-guided high-intensity focused ultrasound. Prenat Diagn 2019; 39:394-402. [PMID: 30820973 DOI: 10.1002/pd.5443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 01/10/2019] [Accepted: 02/23/2019] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Magnetic resonance-guided high-intensity focused ultrasound (MRgHIFU) is a potential noninvasive therapy for fetal conditions. In utero MRgHIFU delivery and proton resonance frequency shift (PRFS) thermometry monitoring will control accuracy of HIFU ablation and confirm in situ tissue heating in a rabbit model. METHODS High-resolution 3T MR images were acquired in late-gestation rabbits (approximately 30 days, n = 5). HIFU sonications, using magnetic resonance (MR) thermometry as a guide, were delivered to achieve necrosis in relevant fetal targets. Thermometry, posttreatment magnetic resonance imaging (MRI), and follow-up histology confirmed ablation. RESULTS Placentas (n = 14) were treated with 127 ± 34 Wac; thermometry-indicated temperatures reached 67°C. Lungs (n = 8) were treated with 85 ± 15 Wac and reached 73°C, livers (n = 6) with 80 ± 15 Wac and reached 74°C, and kidneys (n = 5) with 100 Wac and reached 66°C. Histological changes showed focal areas of necrosis with circumferential hemorrhage and/or vasodilation, which transitioned abruptly to healthy tissue. CONCLUSION MRgHIFU therapy can effectively target and thermally treat specific in utero organs in this acute fetal rabbit model. PRFS gives in situ temperature control of therapy on tissues. Conceivably, MRgHIFU therapy may be applicable to specific fetal organ anomalies clinically and has the potential to improve the overall fetal outcome over traditional invasive surgical procedures.
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Affiliation(s)
- Karolina Piorkowska
- Centre for Image Guided Innovation and Therapeutic Intervention, Hospital for Sick Children, Toronto, Canada
| | - Adam C Waspe
- Centre for Image Guided Innovation and Therapeutic Intervention, Hospital for Sick Children, Toronto, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Tao Wang
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Charles Mougenot
- Imaging Division, University Medical Center, Utrecht, The Netherlands
| | - Greg Ryan
- Department of Medical Imaging, University of Toronto, Toronto, Canada.,Fetal Medicine Program, Mount Sinai Hospital, Toronto, Canada.,Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Canada
| | - James M Drake
- Centre for Image Guided Innovation and Therapeutic Intervention, Hospital for Sick Children, Toronto, Canada.,Faculty of Surgery, University of Toronto, Toronto, Canada.,Division of Neurosurgery, Hospital for Sick Children, Toronto, Canada
| | - Justin T Gerstle
- Centre for Image Guided Innovation and Therapeutic Intervention, Hospital for Sick Children, Toronto, Canada.,Faculty of Surgery, University of Toronto, Toronto, Canada.,Division of General and Thoracic Surgery, Hospital for Sick Children, Toronto, Canada
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20
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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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21
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Tonni G, Grisolia G, Zampriolo P, Prefumo F, Fichera A, Bonasoni P, Lefebvre M, Khung-Savatovsky S, Guimiot F, Rosenblatt J, Araujo Júnior E. TRAP Sequence in Monochorionic/Monoamniotic (MC/MA) Discordant Twins: Two Cases Treated with Fetoscopic Laser Surgery. Fetal Pediatr Pathol 2018; 37:433-447. [PMID: 30636554 DOI: 10.1080/15513815.2018.1526240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Ablation of the acardiac twin umbilical cord in the TRAP protects the normal donor twin. MATERIALS AND METHODS Two case descriptions, one of interstitial laser photocoagulation and one of laser umbilical cord occlusion (L-UCO) of the acardiac twin in monochorionic monoamniotic pregnancies are reported. RESULTS L-UCO in two pregnancies with TRAP syndrome in the second trimester resulted in intrauterine fetal death in both cases after 1 month. Case 1 had no detectable cause of fetal death. Case 2 had rupture of the amniotic sac causing anhydramnios and acute chorioamnionitis. A groove on the umbilical cord of the normal twin indicated a cord stricture due to cord entanglement. CONCLUSION Our experience confirms that the best timing and optimal treatment of MC/MA twins complicated by TRAP sequence still remains a controversial clinical issue. Cord entanglement may continue be a potential clinical risk factor for adverse perinatal outcome even after ablation therapy.
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Affiliation(s)
- Gabriele Tonni
- a Department of Obstetric and Gynecology, Prenatal Diagnostic Service , Reggio Emilia , Italy
| | - Gianpaolo Grisolia
- b Azienda Socio Sanitaria Territoriale di Mantova, Department of Obstetrics and Gynecology , Carlo Poma Hospital , Mantova , Italy
| | - Paolo Zampriolo
- b Azienda Socio Sanitaria Territoriale di Mantova, Department of Obstetrics and Gynecology , Carlo Poma Hospital , Mantova , Italy
| | | | - Anna Fichera
- d Universita degli Studi di Brescia Sezione Materno Infantile, Obstetrics and Gynecology , Brescia , Italy
| | | | - Mathilde Lefebvre
- f Hopital Universitaire Robert-Debre, Unite de Foetopathologie , Paris , France
| | | | - Fabien Guimiot
- f Hopital Universitaire Robert-Debre, Unite de Foetopathologie , Paris , France
| | - Jonathan Rosenblatt
- g Hopital Universitaire Robert-Debre, Obstetrics and Gynecology , Paris , France
| | - Edward Araujo Júnior
- h Paulista School of Medicine - Federal University of São Paulo, Obstetrics , São Paulo , Brazil
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22
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Nassr AA, Erfani H, Fisher JE, Ogunleye OK, Espinoza J, Belfort MA, Shamshirsaz AA. Fetal interventional procedures and surgeries: a practical approach. J Perinat Med 2018; 46:701-715. [PMID: 28599395 DOI: 10.1515/jpm-2017-0015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 04/19/2017] [Indexed: 12/25/2022]
Abstract
Abstract
The identification of congenital birth defects and fetal malformations continues to increase during the antenatal period with improved imaging techniques. Understanding of how to treat specific fetal conditions continues to improve outcomes from these treatment modalities. In an effort to further improvement in this field, we provide a review that begins with a brief background of fetal surgery including the history of fetal surgery, ethics surrounding fetal surgery, and considerations of how to treat the fetus during intervention. A synopsis of the most commonly encountered disease processes treated by fetal intervention/surgery including definitions, treatment modalities, and outcomes following fetal intervention/surgery is then provided. Within the sections describing each disease process, methodology is described that has helped with efficiency and success of procedures performed at our institution.
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Affiliation(s)
- Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA.,Women's Health Hospital, Assiut University, Assiut, Egypt
| | - Hadi Erfani
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - James E Fisher
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Oluseyi K Ogunleye
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, 6651 Main Street, Houston, TX 77030, USA,
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23
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Roethlisberger M, Strizek B, Gottschalk I, Mallmann MR, Geipel A, Gembruch U, Berg C. First-trimester intervention in twin reversed arterial perfusion sequence: does size matter? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:40-44. [PMID: 27390925 DOI: 10.1002/uog.16013] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 06/11/2016] [Accepted: 07/05/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To evaluate the outcome of first-trimester intervention (12 + 0 to 14 + 0 weeks of gestation) in pregnancies complicated by twin reversed arterial perfusion (TRAP) sequence. METHODS All monochorionic diamniotic twin pregnancies diagnosed with TRAP sequence that underwent intrafetal laser ablation (IFL) of the feeding vessels before 14 + 0 weeks of gestation at the University of Bonn between 2010 and 2015 were analyzed retrospectively for intrauterine course and outcome. RESULTS In the study period, 12 pregnancies with TRAP sequence were treated by IFL. Median gestational age at intervention was 13.2 (interquartile range (IQR), 12.6-13.6) weeks. In all cases, one intervention sufficed to disrupt the perfusion of the TRAP twin. There was no case of miscarriage, preterm prelabor rupture of membranes or hemorrhage. In five (41.7%) pregnancies, intrauterine death of the pump twin occurred at a median of 72.0 (IQR, 54.0-90.0; range, 48-96) h after intervention. The remaining seven pregnancies continued uneventfully resulting in birth of a healthy infant at term. A comparison of survivors and non-survivors identified a significant difference in median discordance between crown-rump length (CRL) of the pump twin and upper pole-rump length (URL) of the TRAP twin ((CRL - URL)/CRL ratio, 0.56 vs 0.31; P < 0.05 and URL/CRL ratio, 0.44 vs 0.68; P < 0.05). Survivors were treated at a significantly later gestational age than were non-survivors (median, 13.4 (IQR, 12.9-14.1) vs 12.6 (IQR, 12.5-13.1); P < 0.05). However, none of these parameters independently predicted survival. CONCLUSIONS Although technically feasible, IFL performed in the first trimester for TRAP sequence is associated with a significant fetal loss rate. Gestational age at intervention, (CRL - URL)/CRL ratio and URL/CRL ratio are potential predictors of pregnancy outcome. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M Roethlisberger
- Division of Prenatal Medicine and Gynecologic Sonography, Department of Obstetrics and Gynecology, University of Cologne, Cologne, Germany
| | - B Strizek
- Division of Fetal Surgery, Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | - I Gottschalk
- Division of Prenatal Medicine and Gynecologic Sonography, Department of Obstetrics and Gynecology, University of Cologne, Cologne, Germany
| | - M R Mallmann
- Division of Prenatal Medicine and Gynecologic Sonography, Department of Obstetrics and Gynecology, University of Cologne, Cologne, Germany
| | - A Geipel
- Division of Fetal Surgery, Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | - U Gembruch
- Division of Fetal Surgery, Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | - C Berg
- Division of Prenatal Medicine and Gynecologic Sonography, Department of Obstetrics and Gynecology, University of Cologne, Cologne, Germany
- Division of Fetal Surgery, Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
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24
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Ryu A, Mun ST. A case of twin reversed arterial perfusion (TRAP) sequence misdiagnosed as a chorioangioma. J OBSTET GYNAECOL 2017; 37:533-534. [PMID: 28287285 DOI: 10.1080/01443615.2017.1284772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Aeli Ryu
- a Departments of Obstetrics and Gynaecology , SoonChunHyang University College of Medicine, SoonChunHyang UniversityCheonAn Hospital , CheonAn , Republic of Korea
| | - Seong Taek Mun
- a Departments of Obstetrics and Gynaecology , SoonChunHyang University College of Medicine, SoonChunHyang UniversityCheonAn Hospital , CheonAn , Republic of Korea
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25
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Fisher KE, Welsh AW, Henry A. Uncommon complications of monochorionic twin pregnancies: Twin reversed arterial perfusion sequence. Australas J Ultrasound Med 2016; 19:133-141. [PMID: 34760458 DOI: 10.1002/ajum.12024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Introduction Twin reversed arterial perfusion (TRAP) sequence occurs when there is one non-viable twin without cardiac structures and a viable pump twin that perfuses the acardiac mass. This study aims to investigate the management and immediate neonatal outcomes for monochorionic multiple pregnancies complicated by TRAP referred to the NSW Fetal Therapy Centre (NSW FTC). Methods Retrospective cohort study of multiple pregnancies referred to NSW FTC between April 2006 and April 2014, reviewing data for cases of TRAP sequence (n = 19, including two triplet cases) compared to a timeframe matched sample of uncomplicated monochorionic diamniotic (MCDA) twin pregnancies managed in the unit (n = 45). Results Primary management of the 19 TRAP cases was expectant management in 10 (53%), radiofrequency ablation (RFA) in 6 (32%), and bipolar cord coagulation, amniodrainage and termination of pregnancy in 1 case each. 1 of 6 RFA cases had pump twin demise <1 week post-procedure. Average gestation at birth (35.1 ± 5.0 vs. 35.0 ± 2.8 weeks) and mean birthweight (2157 ± 1019 g vs. 2245 ± 537 g) were similar between TRAP pump fetuses and uncomplicated MCDA cases. Pump twin survival was 81% (twins only) compared to 98% for uncomplicated MCDA twins (P = 0.02), and in 5 of 19 (26%) TRAP pregnancies the pump fetus had a congenital anomaly. Conclusion Mean gestational age at birth and mean birthweight were similar for both TRAP and uncomplicated MCDA pregnancies. TRAP cases, however, had higher perinatal mortality, and high rates of congenital anomaly. The overall neonatal outcome at NSW FTC for TRAP cases is similar to reported international outcomes.
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Affiliation(s)
- Katie E Fisher
- School of Women's and Children's Health University of New South Wales Sydney New South Wales Australia
| | - Alec W Welsh
- School of Women's and Children's Health University of New South Wales Sydney New South Wales Australia.,Department of Maternal-Fetal Medicine Royal Hospital for Women Sydney New South Wales Australia
| | - Amanda Henry
- School of Women's and Children's Health University of New South Wales Sydney New South Wales Australia.,Department of Maternal-Fetal Medicine Royal Hospital for Women Sydney New South Wales Australia
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26
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Mone F, Devaseelan P, Ong S. Intervention versus a conservative approach in the management of TRAP sequence: a systematic review. J Perinat Med 2016; 44:619-29. [PMID: 26356357 DOI: 10.1515/jpm-2015-0165] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 08/13/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE In the management of twin reversed arterial perfusion (TRAP) sequence, we wished to (i) determine if intervention is better than a conservative approach and (ii) assess if any of the apparent adverse prognostic indicators could guide intervention. METHODS A systematic review was conducted between 1994 and 2014. Data extracted were inspected for heterogeneity. Overall rates and confidence intervals (CIs) for each prognostic factor were calculated. Where there were comparative data, the odds ratio (OR) was calculated. RESULTS Twenty-six studies were included in the review. When all cases were considered, intervention either by cord occlusion or by ablation conferred a better survival rate compared with conservative management (OR=2.22, 95% CI 1.23-4.01, heterogeneity I2=37%, P=0.008). This difference was greater in the presence of one or more poor prognostic features (OR=8.58, 95% CI 1.47-49.96, heterogeneity I2=0%, P=0.02). Survival was better using ablative techniques compared to cord occlusion (OR=9.84, 95% CI 1.56-62.00, heterogeneity I2=0%, P=0.01). CONCLUSION Intervention either by cord occlusion or by ablation confers a better survival rate compared to conservative management. This appears more compelling if there are one or more poor prognostic features. Ablative techniques are superior to cord occlusion. There were insufficient data to determine which poor prognostic features should guide management.
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27
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Leszczyńska K, Preis K, Respondek-Liberska M, Słodki M, Wood D, Weiner S, Gembruch U, Rizzo G, Achiron R, Pruetz JD, Sklansky M, Cuneo B, Arabin B, Blickstein I. Recommendations for Fetal Echocardiography in Twin Pregnancy in 2016. PRENATAL CARDIOLOGY 2016. [DOI: 10.1515/pcard-2016-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Progress in the fields of fetal cardiology and fetal surgery have been seen not only in singleton pregnancies but also in multiple pregnancies. Proper interpretation of prenatal echocardiography is critical to clinical decision making, family counseling and perinatal management for obstetricians, maternal fetal medicine specialists, neonatologists and pediatric cardiologists. Fetal echocardiography is one of the most challenging and time-consuming prenatal examinations to perform, especially in multiple gestations. Performing just the basic fetal exam in twin gestations may take an hour or more. Thus, it is not practical to perform this exam in all cases of multiple gestations. Therefore our review and recommendations are related to fetal echocardiography in twin gestation.
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Affiliation(s)
| | - Krzysztof Preis
- 1. Department of Obstetrics, Medical University of Gdansk, Poland
| | - Maria Respondek-Liberska
- 2. Department of Diagnoses and Prevention Fetal Malformations, Medical University of Lodz, Poland
- 3. Department of Prenatal Cardiology, Polish Mother’s Memorial Hospital Research Institute, Lodz, Poland
| | - Maciej Słodki
- 3. Department of Prenatal Cardiology, Polish Mother’s Memorial Hospital Research Institute, Lodz, Poland
- 4. Institute of Health Sciences, The State School of Higher Professional Education in Płock, Poland
| | - Dennis Wood
- 5. Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Stuart Weiner
- 6. Thomas Jefferson University and Hospitals, Philadelphia, Pennsylvania, United States of America
| | - Ulli Gembruch
- 7. Department of Obstetrics and Prenatal Medicine, University Bonn Medical School, Bonn, Germany
| | - Giusseppe Rizzo
- 8. Department of Obstetrics and Gynecology, Università Roma Tor Vergata, Ospedela Fatebenefratelli Isola Tiberina, Rome, Italy
| | - Reuven Achiron
- 9. Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Israel
| | - Jay D Pruetz
- 10. Division of Pediatric Cardiology, Children’s Hospital Los Angeles, Los Angeles, CA, United States of America ; Keck School of Medicine, University of Southern California, Los Angeles, California, United States of America
| | - Mark Sklansky
- 11. Division of Pediatric Cardiology, Department of Pediatrics, David Geffen School of Medicine, Los Angeles, California, United States of America
| | - Bettina Cuneo
- 12. Department of Pediatric Cardiology, Then Fetal Heart Program, Colorado Fetal Care Center, Colorado Institute for Maternal Fetal Health, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Birgit Arabin
- 13. Center for Mother and Child, Philipps University, Marburg, Germany
| | - Isaac Blickstein
- 14. Department of Obstetrics and Gynecology, Kaplan Medical Center, 76100 Rehovot and the Hadassah-Hebrew University School of Medicine, Jerusalem, Israel
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28
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Sugibayashi R, Ozawa K, Sumie M, Wada S, Ito Y, Sago H. Forty cases of twin reversed arterial perfusion sequence treated with radio frequency ablation using the multistep coagulation method: a single-center experience. Prenat Diagn 2016; 36:437-43. [PMID: 26934598 DOI: 10.1002/pd.4800] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 02/17/2016] [Accepted: 02/25/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To report the pregnancy outcomes of patients with twin reversed arterial perfusion (TRAP) sequence treated by radiofrequency ablation (RFA). METHODS This was a retrospective study of TRAP sequences treated in a single center between March 2002 and February 2015. Forty patients underwent RFA with expandable tines through a multistep coagulation method between 15 and 26 gestational weeks. The primary outcome was neonatal survival to discharge. RESULTS The overall survival of the pump twin was 85%. The survival rates in monochorionic-monoamniotic (MCMA) pregnancies and monochorionic-diamniotic pregnancies were 66.7% (4/6) and 87.9% (29/33), respectively. One triplet was treated successfully and delivered at 36 weeks of gestation. One of 35 live births (2.9%) had preterm premature rupture of membranes less than 34 weeks, resulting in infant death. In five intrauterine pump twin deaths, two cases were MCMA twins with cord entanglement, and three cases were MCDA twins with acardius anceps. CONCLUSIONS Our study supports the effectiveness of RFA for TRAP sequence after 15 weeks of gestation. The presence of MCMA twins or acardius anceps is associated with a high risk of pump twin death after RFA. © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Rika Sugibayashi
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Katsusuke Ozawa
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Masahiro Sumie
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Seiji Wada
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yushi Ito
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Haruhiko Sago
- Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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29
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Wagata M, Murakoshi T, Ishii K, Muromoto J, Sasahara J, Murotsuki J. Radiofrequency Ablation with an Internally Cooled Electrode for Twin Reversed Arterial Perfusion Sequence. Fetal Diagn Ther 2016; 40:110-5. [PMID: 26928848 DOI: 10.1159/000442152] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 10/30/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The study aims to evaluate the efficacy of radiofrequency ablation (RFA) with an internally cooled electrode for twin reversed arterial perfusion (TRAP) sequence. METHODS From April 2008 through December 2014, we retrospectively reviewed all patients who underwent RFA with an internally cooled electrode for TRAP sequence at 3 tertiary referral centers in Japan. RESULTS Twenty-five monochorionic diamniotic twin pregnancies underwent RFA with an internally cooled electrode for TRAP sequence at 16-27 weeks of gestation. In all cases, umbilical cord blood flow cessation in the acardiac twin was confirmed by ultrasonography with color Doppler. There were 2 cases of procedure-related complications: 1 case of unintentional septostomy and 1 case of anemia in a pump twin. Fetal demise of the pump twin occurred in 3 (12%) cases. Twenty-two (88%) of 25 pump twins were delivered alive. The median gestational age at delivery was 36 + 3 weeks (range 25 + 2-40 + 5 weeks). There were 14 cases (64%) of premature deliveries before 37 weeks and 5 (23%) before 32 weeks. CONCLUSION RFA with an internally cooled electrode is a feasible and effective procedure for the treatment of TRAP sequence.
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Affiliation(s)
- Maiko Wagata
- Division of Perinatology, Fetal Diagnosis and Therapy, Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan
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30
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The North American Fetal Therapy Network Consensus Statement: Management of Complicated Monochorionic Gestations. Obstet Gynecol 2015; 126:575-584. [PMID: 26244534 DOI: 10.1097/aog.0000000000000994] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The North American Fetal Therapy Network is a consortium of 30 medical institutions in the United States and Canada with established expertise in fetal therapy and other forms of multidisciplinary care for complex fetal disorders. This publication is the third in a series of articles written by NAFTNet about monochorionic pregnancies. In this article, we provide the general obstetric practitioner with information regarding management options available for complications of monochorionic gestations. This information may be useful for a better understanding of the pathophysiology of the various conditions, for better patient counseling, for timely referral to a regional treatment center, and for ongoing comanagement after treatment.
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Gaerty K, Greer RM, Kumar S. Systematic review and metaanalysis of perinatal outcomes after radiofrequency ablation and bipolar cord occlusion in monochorionic pregnancies. Am J Obstet Gynecol 2015; 213:637-43. [PMID: 25935786 DOI: 10.1016/j.ajog.2015.04.035] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 03/31/2015] [Accepted: 04/24/2015] [Indexed: 11/29/2022]
Abstract
The aim of this study was to analyze perinatal outcomes after selective reduction in monochorionic pregnancies with the use of either radiofrequency ablation (RFA) or bipolar cord occlusion (BCO). This was a systematic review and metaanalysis that included all studies with ≥5 cases that described perinatal outcomes after BCO or RFA that were identified in PubMed, Embase, Web of Science, COCHRANE, CINAHL, Academic Search Premier, Science Direct, and MEDLINE that were published between 1965 and July 2014. For count data, incidence risk ratios (IRR; 95% confidence interval [CI]) were calculated with BCO as the reference standard. The analysis included 481 cases of BCO and 320 cases of RFA from 17 studies. The mean median gestations at procedure were 21.1 ± 1.2 weeks (BCO) and 18.8 ± 2.5 weeks (RFA; P = .03). The rate of cotwin death was higher in the RFA group (14.7%) vs the BCO group (10.6%; IRR, 1.38; 95% CI, 0.93-2.05; P = .11). The live birth rate was 81.3% for the RFA group and 86.7% in the BCO group (IRR, 0.93; 95% CI, 0.80-1.09; P = .41). BCO had higher neonatal death rates (8.1%) vs RFA (4.5%; IRR, 0.56; 95% CI, 0.30-1.04; P = .07). Overall survival was 76.8% for RFA and 79.1% for BCO (IRR, 0.97; 95% CI, 0.82-1.14; P = .72); however, none of these differences were statistically significant. Preterm premature rupture of membranes occurred in 17.7% of RFA cases and 28.2% of the BCO cases (IRR, 0.63; 95% CI, 0.43-0.91; P = .01). The mean median gestational age at delivery was 34.7 ± 1.7 weeks in the RFA group and 35.1 ± 1.6 weeks in the BCO group. Our data do not demonstrate clearly the superiority of 1 procedure over the other. The clinical situation and preference of the operator are important considerations. Rates of preterm delivery and preterm premature rupture of membranes remain substantial for both procedures.
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Affiliation(s)
- Kirsten Gaerty
- Mater Mothers' Hospital, South Brisbane, Queensland, Australia
| | - Ristan M Greer
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
| | - Sailesh Kumar
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia; Mater Mothers' Hospital, South Brisbane, Queensland, Australia.
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Buyukkaya A, Tekbas G, Buyukkaya R. Twin Reversed Arterial Perfusion (TRAP) Sequence; Characteristic Gray-Scale and Doppler Ultrasonography Findings. IRANIAN JOURNAL OF RADIOLOGY 2015; 12:e14979. [PMID: 26557268 PMCID: PMC4632132 DOI: 10.5812/iranjradiol.12(3)2015.14979] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Accepted: 02/01/2014] [Indexed: 01/03/2023]
Abstract
Twin reversed arterial perfusion (TRAP) sequence is a syndrome with poor prognosis, seen only in monochorionic monozygotic twin pregnancies. The incidence is one in 35.000 births and one in 100 monozygotic twin pregnancies. It is characterized with a recipient fetus exhibiting lethal anomalies including acardia and a pump fetus. Mortality is usually due to heart failure or premature labor caused by polyhydramnios of pump fetus. Herein, we report a case of TRAP sequence that emphasizes the importance of gray-scale and color Doppler imaging in the diagnosis and management of TRAP sequence.
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Affiliation(s)
- Ayla Buyukkaya
- Department of Radiology, Duzce Ataturk Government Hospital, Duzce, Turkey
- Corresponding author: Ayla Buyukkaya, Department of Radiology, Duzce Ataturk Government Hospital, Duzce, Turkey. Tel: +90-3805421390, Fax: +90-3805421387, E-mail:
| | - Guven Tekbas
- Department of Radiology, School of Medicine, Dicle University, Diyarbakır, Turkey
| | - Ramazan Buyukkaya
- Department of Radiology, School of Medicine, Duzce University, Duzce, Turkey
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Pepe F, Teodoro MC, Luca C, Privitera F. Conservative management in a case of uncomplicated trap sequence: a case report and brief literature review. J Prenat Med 2015; 9:29-34. [PMID: 27358695 PMCID: PMC4909109 DOI: 10.11138/jpm/2015.9.3.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION twin reversed arterial perfusion (TRAP) sequence is a rare anomaly that occurs in monochorionic twins with overall mortality rate ranging from 50% to 70% in the normal fetus, above all for congestive cardiac failure. CASE REPORT a 31-year-old Caucasian gravida was referred to our fetomaternal medicine unit in the 25 gestational age. Ultrasound examination revealed a monochorionic, biamniotic twin pregnancy with a donor fetus showing normal morphology and growth corresponding to gestational age. The recipient twin appeared grossly abnormal with no head, upper limbs, heart, or thoracic structures and massive, diffuse, soft tissue edema. Fetal Doppler and fetal echocardiography revealed normal parameters. The patient refused any treatment and was monitored with weekly ultrasonography and Doppler ultrasound examination. She underwent cesarean section due to premature labor/rupture of membranes secondary to a mild polyhydramnios, at 36 weeks gestational age and delivered an apparent normal female live baby weighing 2550 gr, and another female acardius acephalus twin, birth weight 1300 gr. This baby had rudimental edematous lower limbs, pelvic bone, lower sacral vertebrae, and absence of thorax and cephalic structures. CONCLUSION although the literature suggest that early intrafetal laser treatment of TRAP sequence is advantageous, our case shows that pregnancies referred late would still require a tailored approach after a risk-benefit assessment.
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Takano M, Murata S, Fujiwara M, Hirata H, Nakata M. Experience of fetoscopic laser photocoagulation and cord transection for twin-reversed arterial perfusion sequence. J Obstet Gynaecol Res 2015; 41:1326-9. [PMID: 26017111 DOI: 10.1111/jog.12720] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 02/26/2015] [Indexed: 11/30/2022]
Abstract
AIM The purpose of this study was to evaluate the usefulness of fetoscopic laser photocoagulation of placental communicating vessels or umbilical cord for twin-reversed arterial perfusion (TRAP) sequence. MATERIAL AND METHODS We report a retrospective case series of all cases of TRAP sequence identified from 2006 to 2014 at out institutions. Fetoscopic laser photocoagulation of placental arterioarterial and venovenous anastomoses was performed in diamniotic twins, and in cases of monoamniotic twins we performed laser photocoagulation and transection of the umbilical cord of the acardiac twin to prevent cord entanglement. Pregnancy and perinatal outcomes were estimated. RESULTS Ten cases were included in the study. The median gestational age at procedure was 21.3 weeks (range, 16.7-27.3 weeks). All cases completed the procedure. Two cases were treated with laser photocoagulation and transection of the umbilical cord of the acardiac twin. No major immediate complications were noted. Preterm rupture of membranes occurred in four cases (40%). One case resulted in miscarriage. The other fetuses were delivered alive. Median gestational age at delivery was 35.4 weeks (range, 25.6-42.0 weeks). Median interval of treatment to delivery was 85 days (range, 43-153 days). Five out four infants were delivered preterm. The overall neonatal survival was 9/10. CONCLUSION This case series demonstrated favorable outcome, and fetoscopic laser photocoagulation seems to be a useful treatment for TRAP sequence. In particular, transection of the umbilical cord is effective to prevent cord entanglement of monoamniotic twins.
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Affiliation(s)
- Mayumi Takano
- Department of Obstetrics and Gynecology, Kawasaki Medical School, Okayama, Japan.,Department of Obstetrics and Gynecology, Tokuyama Central Hospital, Shunan, Japan
| | - Susumu Murata
- Department of Obstetrics and Gynecology, Kawasaki Medical School, Okayama, Japan
| | - Michihisa Fujiwara
- Department of Obstetrics and Gynecology, Kawasaki Medical School, Okayama, Japan
| | - Hiroko Hirata
- Department of Obstetrics and Gynecology, Tokuyama Central Hospital, Shunan, Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Kawasaki Medical School, Okayama, Japan.,Department of Obstetrics and Gynecology, Tokuyama Central Hospital, Shunan, Japan
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Mathis J, Raio L, Baud D. Fetal laser therapy: applications in the management of fetal pathologies. Prenat Diagn 2015; 35:623-36. [DOI: 10.1002/pd.4587] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 02/21/2015] [Accepted: 02/26/2015] [Indexed: 12/23/2022]
Affiliation(s)
- Jérôme Mathis
- Swiss Fetal Laser Group; University Hospital of Bern, University Hospital of Lausanne CHUV; Lausanne Switzerland
| | - Luigi Raio
- Swiss Fetal Laser Group; University Hospital of Bern, University Hospital of Lausanne CHUV; Lausanne Switzerland
| | - David Baud
- Swiss Fetal Laser Group; University Hospital of Bern, University Hospital of Lausanne CHUV; Lausanne Switzerland
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Peyvandi S, Feldstein VA, Hirose S, Rand L, Brook MM, Moon-Grady AJ. Twin-reversed arterial perfusion sequence associated with decreased fetal cerebral vascular impedance. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:447-51. [PMID: 25157457 PMCID: PMC4503362 DOI: 10.1002/uog.14650] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 08/10/2014] [Accepted: 08/13/2014] [Indexed: 05/04/2023]
Abstract
OBJECTIVES Twin-reversed arterial perfusion (TRAP) sequence affects 1% of monochorionic twin pregnancies and is caused by abnormal vascular connections between a pump twin and an acardiac mass. The effects of abnormal vascular connections on cerebral vasculature in the pump twin are unknown. We hypothesize that abnormal cerebral vascular impedance, as assessed by the pulsatility index (PI), is present in pump twins and that fetal intervention alters cerebral impedance. METHODS Fetal echocardiograms performed between 2010 and 2013 in pregnancies diagnosed with TRAP (n = 19), recorded at presentation, and uncomplicated monochorionic twin pregnancies (controls, n = 18; 36 fetuses) were analyzed. In all subjects, the middle cerebral artery (MCA)-PI, combined cardiac output (CCO) and cardiothoracic ratio were calculated, and the values for cases and controls were compared. RESULTS The mean gestational age at the time of echocardiography was 20 weeks in both groups. MCA-PI was lower in TRAP cases than in controls (1.55 (95% CI, 1.47-1.64) vs 1.74 (95% CI, 1.65-1.82), respectively; P = 0.004). CCO in TRAP cases was mildly elevated for gestational age (199.7 (95% CI, 138.4-261.1) mL/min) compared with that of controls (131.4 (95% CI, 102.2-160.7) mL/min). In six TRAP cases with a second echocardiogram available, the mean MCA-PI increased after intervention, from 1.5 (95% CI, 1.3-1.7) to 1.8 (95% CI, 1.4-2.2). CONCLUSIONS TRAP pump twins have lower cerebral vascular impedance than do controls, suggestive of a brain-sparing effect. MCA-PI appeared to increase in a small group of pump twins after intervention. These findings suggest a fetal cerebral autoregulatory response to a high cardiac output state that begins to change after fetal intervention. The long-term implications for neurodevelopmental outcome warrant further study.
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Affiliation(s)
- S. Peyvandi
- Division of Cardiology, Department of Pediatrics, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
- The Fetal Treatment Center, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
| | - V. A. Feldstein
- The Fetal Treatment Center, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
- Department of Radiology, University of California San Francisco, San Francisco, CA, USA
- Department of Obstetrics and Gynecology, University of California San Francisco, San Francisco, CA, USA
| | - S. Hirose
- The Fetal Treatment Center, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
- Division of Pediatric Surgery, Department of Surgery, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
| | - L. Rand
- The Fetal Treatment Center, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
- Department of Obstetrics and Gynecology, University of California San Francisco, San Francisco, CA, USA
| | - M. M. Brook
- Division of Cardiology, Department of Pediatrics, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
- The Fetal Treatment Center, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
| | - A. J. Moon-Grady
- Division of Cardiology, Department of Pediatrics, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
- The Fetal Treatment Center, University of California San Francisco Benioff Children’s Hospital, San Francisco, CA, USA
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Khanduri S, Chhabra S, Raja A, Bhagat S. Twin Reversed Arterial Perfusion Sequence: A Rare Entity. J Clin Imaging Sci 2015; 5:9. [PMID: 25861543 PMCID: PMC4374195 DOI: 10.4103/2156-7514.152341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 02/20/2015] [Indexed: 11/04/2022] Open
Abstract
Twin reversed arterial perfusion (TRAP) sequence is an extremely rare complication of monochorionic multi-fetal pregnancy, occurring once in 35,000 births. This condition is characterized by a malformed fetus without a cardiac pump being perfused by a structurally normal (pump) twin via an artery-to-artery anastomosis in a reverse direction. We report a case of a primigravida, who came for routine antenatal checkup to our hospital at 31 weeks gestational age. Ultrasound imaging and magnetic resonance imaging revealed twin monochorionic intrauterine pregnancy with a viable, normal-appearing first twin and amorphous structured second twin connected by umbilical vessels. The patient was monitored with weekly ultrasonography, echocardiography, and Doppler ultrasound examination to ascertain the well-being of the pump twin. She delivered successfully at term a normal live baby and an acardius acephalus fetus. Plain X-ray of the acardius acephalus fetus confirmed the absence of cephalic structures. The perinatal mortality of the pump twin ranges from 35 to 55%; hence, it is essential to diagnose the presence of a pump twin at an early gestational age through improved imaging techniques, so that intervention can be planned early in the pregnancy for a better outcome of the pump twin.
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Affiliation(s)
- Sachin Khanduri
- Department of Radiodiagnosis, Era's Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India
| | - Saakshi Chhabra
- Department of Radiodiagnosis, Era's Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India
| | - Anshul Raja
- Department of Radiodiagnosis, Era's Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India
| | - Saurav Bhagat
- Department of Radiodiagnosis, Era's Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India
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Thilaganathan B. Ushering in a new dawn in obstetrics and gynecology: the industry of cell-free DNA testing. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:1-3. [PMID: 25557843 DOI: 10.1002/uog.14744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Berg C, Köninger A, Gembruch U, Geipel A. Twin reversed arterial perfusion (TRAP) sequence--does monoamniocity preclude early intervention? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:241-242. [PMID: 24585394 DOI: 10.1002/uog.13349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Accepted: 02/19/2014] [Indexed: 06/03/2023]
Affiliation(s)
- C Berg
- Division of Prenatal Medicine and Gynecologic Sonography, Department of Obstetrics and Gynecology, University of Cologne, Cologne, Germany; Division of Fetal Surgery, Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
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Chaveeva P, Poon LC, Sotiriadis A, Kosinski P, Nicolaides KH. Optimal Method and Timing of Intrauterine Intervention in Twin Reversed Arterial Perfusion Sequence: Case Study and Meta-Analysis. Fetal Diagn Ther 2014; 35:267-79. [DOI: 10.1159/000358593] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 12/30/2013] [Indexed: 11/19/2022]
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Prefumo F, Fichera A, Zanardini C, Frusca T. Fetoscopic cord transection for treatment of monoamniotic twin reversed arterial perfusion sequence. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:234-235. [PMID: 24151190 DOI: 10.1002/uog.13229] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- F Prefumo
- Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynaecology, University of Brescia, Brescia, Italy
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