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Mustafa HJ, Aghajani F, Patrick E, Baerz MM, Arias‐Sánchez P, Khalil A. Perinatal outcomes following fetoscopic laser surgery for early twin-to-twin transfusion syndrome: Systematic review and meta-analysis. Acta Obstet Gynecol Scand 2024; 103:824-831. [PMID: 38415823 PMCID: PMC11019523 DOI: 10.1111/aogs.14806] [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: 10/26/2023] [Revised: 01/08/2024] [Accepted: 01/31/2024] [Indexed: 02/29/2024]
Abstract
INTRODUCTION Our objective was to investigate outcomes in twin-to-twin transfusion syndrome (TTTS) treated with fetoscopic laser surgery (FLS) at <18 weeks vs ≥18 weeks, and to conduct subgroup analysis of TTTS with FLS at <16 weeks vs 16-18 weeks. MATERIAL AND METHODS PubMed, Scopus and Web of Science were searched systematically from inception until May 2023. Primary outcome was survival, and secondary outcomes included preterm premature rupture of membranes (PPROM), preterm birth and gestational age (GA) at delivery. RESULTS Nine studies encompassing 1691 TTTS pregnancies were included. TTTS stage III was significantly more common in TTTS pregnancies treated with FLS at <18 weeks (odds ratio [OR] 2.84, 95% confidence interval [CI] 1.24-6.54), and procedure duration was shorter at <18 weeks (MD -5.27 minutes, 95% CI -9.19 to -1.34). GA at delivery was significantly earlier in TTTS pregnancies treated with FLS at <18 weeks (MD -3.12 weeks, 95% CI -6.11 to -0.13). There were no significant differences in outcomes, including PPROM, PPROM at <7 days post-FLS, preterm birth at <28 and <32 weeks, delivery at <7 days post-FLS, and survival outcomes, including fetal demise, live birth and neonatal survival. Similarly, TTTS stage III was more common in TTTS with FLS at <16 weeks than at 16-18 weeks (OR 2.95, 95% CI 1.62-5.35), with no significant differences in the aforementioned outcomes. CONCLUSIONS In early TTTS treated with FLS, outcomes were comparable between those treated at <18 weeks compared with ≥18 weeks except for GA at delivery, which was 3 weeks earlier. In the subset treated at <16 weeks vs 16-18 weeks, the procedure was feasible without an increased risk of very early preterm birth or perinatal mortality.
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Affiliation(s)
- Hiba J. Mustafa
- Division of Maternal‐Fetal MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- The Fetal Center at Riley Children's and Indiana University HealthIndianapolisIndianaUSA
| | - Faezeh Aghajani
- BCNatal Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de DéuUniversitat de BarcelonaBarcelonaSpain
| | - Elise Patrick
- Indiana University School of MedicineIndianapolisIndianaUSA
| | - Maryam M. Baerz
- School of MedicineIran University of Medical SciencesTehranIran
| | | | - Asma Khalil
- Fetal Medicine Unit, St George's HospitalSt George's University of LondonLondonUK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research InstituteSt George's University of LondonLondonUK
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2
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Hernansanz A, Parra J, Sayols N, Eixarch E, Gratacós E, Casals A. Robot assisted Fetoscopic Laser Coagulation: Improvements in navigation, re-location and coagulation. Artif Intell Med 2024; 147:102725. [PMID: 38184348 DOI: 10.1016/j.artmed.2023.102725] [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: 06/21/2022] [Revised: 11/24/2023] [Accepted: 11/24/2023] [Indexed: 01/08/2024]
Abstract
Fetoscopic Laser Coagulation (FLC) for Twin to Twin Transfusion Syndrome is a challenging intervention due to the working conditions: low quality images acquired from a 3 mm fetoscope inside a turbid liquid environment, local view of the placental surface, unstable surgical field and delicate tissue layers. FLC is based on locating, coagulating and reviewing anastomoses over the placenta's surface. The procedure demands the surgeons to generate a mental map of the placenta with the distribution of the anastomoses, maintaining, at the same time, precision in coagulation and protecting the placenta and amniotic sac from potential damages. This paper describes a teleoperated platform with a cognitive-based control that provides assistance to improve patient safety and surgery performance during fetoscope navigation, target re-location and coagulation processes. A comparative study between manual and teleoperated operation, executed in dry laboratory conditions, analyzes basic fetoscopic skills: fetoscope navigation and laser coagulation. Two exercises are proposed: first, fetoscope guidance and precise coagulation. Second, a resolved placenta (all anastomoses are indicated) to evaluate navigation, re-location and coagulation. The results are analyzed in terms of economy of movement, execution time, coagulation accuracy, amount of coagulated placental surface and risk of placenta puncture. In addition, new metrics, based on navigation and coagulation maps evaluate robotic performance. The results validate the developed platform, showing noticeable improvements in all the metrics.
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Affiliation(s)
- Albert Hernansanz
- Research Centre for Biomedical Engineering, Technical University of Catalonia, CREB-UPC, 08034 Barcelona, Spain; Simulation, Imaging and Modelling for Biomedical Systems (SIMBIOsys-UPF), Barcelona, Spain.
| | - Johanna Parra
- BCNatal Fetal Medicine Research Center (Hospital Clinic and Hospital Sant Joan de Deu), 08950 Esplugues de Llobregat, Spain
| | - Narcís Sayols
- Research Centre for Biomedical Engineering, Technical University of Catalonia, CREB-UPC, 08034 Barcelona, Spain; Simulation, Imaging and Modelling for Biomedical Systems (SIMBIOsys-UPF), Barcelona, Spain
| | - Elisenda Eixarch
- BCNatal Fetal Medicine Research Center (Hospital Clinic and Hospital Sant Joan de Deu), 08950 Esplugues de Llobregat, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Eduard Gratacós
- BCNatal Fetal Medicine Research Center (Hospital Clinic and Hospital Sant Joan de Deu), 08950 Esplugues de Llobregat, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Alícia Casals
- Research Centre for Biomedical Engineering, Technical University of Catalonia, CREB-UPC, 08034 Barcelona, Spain
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3
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Olutoye OO, Joyeux L, King A, Belfort MA, Lee TC, Keswani SG. Minimally Invasive Fetal Surgery and the Next Frontier. Neoreviews 2023; 24:e67-e83. [PMID: 36720693 DOI: 10.1542/neo.24-2-e67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Most patients with congenital anomalies do not require prenatal intervention. Furthermore, many congenital anomalies requiring surgical intervention are treated adequately after birth. However, there is a subset of patients with congenital anomalies who will die before birth, shortly after birth, or experience severe postnatal complications without fetal surgery. Fetal surgery is unique in that an operation is performed on the fetus as well as the pregnant woman who does not receive any direct benefit from the surgery but rather lends herself to risks, such as hemorrhage, abruption, and preterm labor. The maternal risks involved with fetal surgery have limited the extent to which fetal interventions may be performed but have, in turn, led to technical innovations that have significantly advanced the field. This review will examine congenital abnormalities that can be treated with minimally invasive fetal surgery and introduce the next frontier of prenatal management of fetal surgical pathology.
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Affiliation(s)
- Oluyinka O Olutoye
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Luc Joyeux
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Michael A Belfort
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Timothy C Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Sundeep G Keswani
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
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4
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Agrawal P, Vaidya A, Vaidya A, Phuyal S, Pandey A. Twin to Twin Transfusion Syndrome: A Case Report. JNMA J Nepal Med Assoc 2022; 60:1056-1058. [PMID: 36705118 PMCID: PMC9795135 DOI: 10.31729/jnma.5574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 10/20/2022] [Indexed: 12/03/2022] Open
Abstract
Twin-twin transfusion syndrome occurs in multiple gestations and involves a chronic flow of blood from one twin to another twin and is a rare entity. We present a case of 32-years-old primigravida with a twin pregnancy who presented with increasing abdominal girth inappropriate with her gestational age at 21 weeks of her pregnancy. Ultrasound findings were suggestive of twin-twin transfusion syndrome. The patient was provided with treatment options but due to polyhydramnios and short cervix, the patient went into spontaneous labour the same day with a poor pregnancy outcome. Twin-twin transfusion syndrome leads to a high rate of perinatal morbidity due to its poorly understood aetiology and difficulty in diagnosing and treatment. Early diagnosis during antenatal ultrasound is important in reducing morbidity and mortality rates. Keywords case reports; fetoscopy; oligohydramnios; polyhydramnios; twins.
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Affiliation(s)
- Pooja Agrawal
- Department of Radiology, Norvic International Hospital, Thapathali, Kathmandu, Nepal,Correspondence: Dr Pooja Agrawal, Department of Radiology, Norvic International Hospital, Nepal. , Phone: +977-9801133668
| | - Achala Vaidya
- Department of Obstetrics and Gynecology, Norvic International Hospital, Thapathali, Kathmandu, Nepal
| | - Anshu Vaidya
- Department of Obstetrics and Gynecology, Norvic International Hospital, Thapathali, Kathmandu, Nepal
| | - Subash Phuyal
- Department of Radiology, Grande International Hospital, Tokha, Kathmandu, Nepal
| | - Asmita Pandey
- Department of Obstetrics and Gynecology, Norvic International Hospital, Thapathali, Kathmandu, Nepal
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Boyd F, Ledingham MA, Yao W. Development of A Multi-Modality Navigational Based Training System for Fetoscopic Surgical Therapy. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2022; 2022:637-640. [PMID: 36086099 DOI: 10.1109/embc48229.2022.9871328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Fetal surgery is regarded as a technically difficult and new field of research, requiring the use of fetoscopic and ultrasound (US) navigation to perform minimally invasive procedures within the amniotic cavity. The Surgical Apprenticeship Training model (SAT) centres around the subjective assessment of a surgical resident's cognitive competency and technical skills under proctorship using opportunity-based environments. The restrictiveness and rarity of fetal procedures limit the effectiveness of the SAT model, resulting in a slow learning curve (LC) and higher procedural complication rates. This paper aimed to investigate the use of optical tracking technology to construct a novel simulated training system and accompanying scoring assessment under the Proficiency-Based Training model (PBT), providing real-time positional feedback of surgical tools and a quantitative feedback assessment of a surgical resident's technical skills. Clinical Relevance- Clinical feedback deemed the system as valid and confirmed that this novel approach to surgical training will significantly benefit smaller clinics that lack opportunity-based environments. Clinical feedback also suggested that the training system could be adapted to provide access to complex surgical training across the world.
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6
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Behrendt N, Galan HL. Fetal Growth in Multiple Gestations: Evaluation and Management. Obstet Gynecol Clin North Am 2021; 48:401-417. [PMID: 33972074 DOI: 10.1016/j.ogc.2021.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Multifetal gestation pregnancies present a clinical challenge due to unique complications including growth issues, prematurity, maternal risk, and pathologic processes, such as selective intrauterine growth restriction (sIUGR), twin-to-twin transfusion syndrome (TTTS), and twin anemia-polycythemia sequence. If sIUGR is found, then management may involve some combination of increased surveillance, fetal procedures, and/or delivery. The combination of sIUGR with TTTS or other comorbidities increases the risk of pregnancy complications. Multifetal pregnancy reduction is an option when a problem is confined to a single fetus or when weighing the risks and benefits of a multifetal gestation in comparison to a singleton pregnancy.
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Affiliation(s)
- Nicholas Behrendt
- Division of Maternal-Fetal Medicine, University of Colorado, Children's Hospital Colorado, Colorado Fetal Care Center, 12631 East 17th Avenue, Box B198-5, Aurora, CO 80045, USA.
| | - Henry L Galan
- Division of Maternal-Fetal Medicine, University of Colorado, Children's Hospital Colorado, Colorado Fetal Care Center, 12631 East 17th Avenue, Box B198-5, Aurora, CO 80045, USA
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7
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Early postnatal cardiac manifestations are associated with perinatal brain injury in preterm infants with twin to twin transfusion syndrome. Sci Rep 2019; 9:18505. [PMID: 31811241 PMCID: PMC6898644 DOI: 10.1038/s41598-019-54951-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 11/12/2019] [Indexed: 11/09/2022] Open
Abstract
Altered hemodynamics associated with twin to twin transfusion syndrome (TTTS) can be manifested in the fetal and neonatal heart. This study evaluated the association between cardiac manifestations immediately after birth and brain injury in preterm infants with TTTS. Medical records of preterm infants who were born at <35 weeks of gestation with TTTS and admitted to the neonatal intensive care unit at Seoul National University Children's Hospital between January 2011 and January 2018 were reviewed. TTTS was prenatally diagnosed and staged according to the Quintero criteria. Echocardiographic findings, brain ultrasound and MRI imaging findings were analyzed. Fifty-three infants were enrolled in this study. Thirty-two infants (60.3%) were treated by fetoscopic laser coagulation. Brain injury developed in 15 infants (28.3%). Hypotension within the first week and immediate postnatal cardiac manifestations were more prevalent in the brain injury group. In the multivariate analysis, acute kidney injury and cardiac manifestations, such as ventricular dysfunction and tricuspid regurgitation, were statistically associated with brain injury in the study population. Immediate postnatal cardiac manifestations, such as ventricular dysfunction and tricuspid regurgitation, can serve as surrogate markers for perinatal hemodynamic disturbance, which are associated with early neonatal brain injury in preterm infants with TTTS.
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8
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Suzuki T, Kagami K, Mitani Y, Yamazaki R, Ono M, Fujiwara H. Twin anemia‐polycythemia sequence with blood chimerism in monochorionic dizygotic opposite‐sex twins. J Obstet Gynaecol Res 2019; 45:1201-1204. [DOI: 10.1111/jog.13949] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 02/11/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Takuma Suzuki
- Department of Obstetrics and Gynecology, Graduate School of Medical SciencesKanazawa University Ishikawa Japan
- Department of Obstetrics and GynecologyToyama Prefectural Central Hospital Toyama Japan
| | - Kyosuke Kagami
- Department of Obstetrics and Gynecology, Graduate School of Medical SciencesKanazawa University Ishikawa Japan
| | - Yusuke Mitani
- Department of Pediatrics, Graduate School of Medical SciencesKanazawa University Ishikawa Japan
| | - Rena Yamazaki
- Department of Obstetrics and Gynecology, Graduate School of Medical SciencesKanazawa University Ishikawa Japan
| | - Masanori Ono
- Department of Obstetrics and Gynecology, Graduate School of Medical SciencesKanazawa University Ishikawa Japan
| | - Hiroshi Fujiwara
- Department of Obstetrics and Gynecology, Graduate School of Medical SciencesKanazawa University Ishikawa Japan
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9
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Wataganara T, Gosavi A, Nawapun K, Vijayakumar PD, Phithakwatchara N, Choolani M, Su LL, Biswas A, Mattar CNZ. Model Surgical Training: Skills Acquisition in Fetoscopic Laser Photocoagulation of Monochorionic Diamniotic Twin Placenta Using Realistic Simulators. J Vis Exp 2018. [PMID: 29630059 DOI: 10.3791/57328] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Fetoscopic laser coagulation of arterio-venous anastomoses (AVA) in a monochorionic placenta is the standard of care for twin-twin transfusion syndrome (TTTS), but is technically challenging and can lead to significant complications. Acquiring and maintaining the necessary surgical skills require consistent practice, a critical caseload, and time. Training on realistic surgical simulators can potentially shorten this steep learning curve and enables several proceduralists to acquire procedure-specific skills simultaneously. Here we describe realistic simulators designed to allow the user familiarity with the equipment and specific steps required in the surgical treatment of TTTS, including fetoscopic handling, approaches to anterior and posterior placenta, recognition of anastomoses, and efficient coagulation of vessels. We describe the skills that are especially important in conducting placental laser coagulation that the surgeon can practice on the model and apply in a clinical case. These models can be adapted easily depending on the availability of materials and require standard fetoscopy equipment. Such training systems are complementary to traditional surgical apprenticeships and can be useful aids for fetal medicine units that provide this clinical service.
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Affiliation(s)
- Tuangsit Wataganara
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital
| | - Arundhati Gosavi
- Department of Obstetrics and Gynaecology, National University Health Systems
| | - Katika Nawapun
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital
| | | | - Nisarat Phithakwatchara
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Faculty of Medicine, Siriraj Hospital
| | - Mahesh Choolani
- Department of Obstetrics and Gynaecology, National University Health Systems; Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore
| | - Lin Lin Su
- Department of Obstetrics and Gynaecology, National University Health Systems; Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore
| | - Arijit Biswas
- Department of Obstetrics and Gynaecology, National University Health Systems; Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore
| | - Citra N Z Mattar
- Department of Obstetrics and Gynaecology, National University Health Systems; Experimental Fetal Medicine Group, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore;
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10
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Depression, anxiety, and mental health service experiences of women with a twin-twin transfusion syndrome pregnancy. Arch Womens Ment Health 2018; 21:75-83. [PMID: 28761987 DOI: 10.1007/s00737-017-0758-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 07/03/2017] [Indexed: 01/04/2023]
Abstract
Symptoms of emotional distress during and after pregnancy may be introduced or exacerbated by unexpected medical conditions in the mother or fetus. Twin-twin transfusion syndrome (TTTS), which accounts for 17% of fetal deaths in twins and entails substantial medical uncertainty, may represent a particularly challenging pregnancy experience. Yet, little is known about the impact of TTTS on women's emotional health. We retrospectively surveyed 350 women who experienced a TTTS pregnancy about their experiences at three time points (prior to, during, and after pregnancy) to examine symptoms of anxiety and depression, mental health diagnoses, thoughts of seeking mental healthcare, help received, and preferred mental health services. Women in this study experienced significantly elevated symptoms of depression and anxiety during and after pregnancy, regardless of their pregnancy outcome (double survivor, single survivor, or double loss). Women reported feeling devastated by their experience and indicated they would have accepted mental healthcare had it been offered and had barriers to care been addressed. Prospective studies of women experiencing TTTS pregnancies are needed to examine TTTS effects on maternal mental health and to determine how to best address emotional care needs.
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Finneran MM, Templin MA, Stephenson CD. Risk of donor demise after laser therapy for twin–twin transfusion when complicated by growth discordance and abnormal umbilical artery Doppler findings*. J Matern Fetal Neonatal Med 2017; 32:1332-1336. [DOI: 10.1080/14767058.2017.1404983] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Matthew M. Finneran
- Department of Obstetrics and Gynecology, Charlotte Fetal Care Center, Charlotte, NC, USA
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Megan A. Templin
- Center for Outcomes Research and Evaluation, Carolinas Healthcare System, Charlotte, NC, USA
| | - Courtney D. Stephenson
- Department of Obstetrics and Gynecology, Charlotte Fetal Care Center, Charlotte, NC, USA
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12
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Unusual Twinning Resulting in Chimerism: A Systematic Review on Monochorionic Dizygotic Twins. Twin Res Hum Genet 2017; 20:161-168. [DOI: 10.1017/thg.2017.4] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Traditionally, it is understood that dizygotic (DZ) twins always have a dichorionic placenta. However, with 8% blood chimerism in DZ twins, placental sharing is probably more common than previously has been recognized. In this article, we will review all available cases of monochorionic dizygotic (MCDZ) twins. A total of 31 twins have been described in literature. A monochorionic diamniotic placenta is reported in all cases. Assisted reproductive technology is responsible for the origin of the pregnancy in 82.1% of the cases. In 15.4% of the sex-discordant twins, a genital anomaly was reported in one of the twins. Chimerism is demonstrable in 90.3% of the twins, leading to various diagnostic difficulties. As this review shows that most MCDZ twins are discovered by accident, it can be argued that it is far more common than has been assumed until now. However, the prevalence is still unclear. Awareness of MCDZ twinning is important, with subsequently correct medical strategies. Similarly, the resulting (blood) chimerism is essential to consider in diagnostic procedures, pre- and postnatally. More research on the effect of placental transfusion between sex-discordant twins is required.
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Abstract
PURPOSE OF REVIEW Twin-to-twin transfusion syndrome (TTTS) is an uncommon, but dangerous, complication of monochorionic diamniotic twin gestations. The purpose of this review is to provide an update on the evolving treatments in TTTS as it pertains primarily to laser photocoagulation, as well as to provide recently published information on outcomes. RECENT FINDINGS The Solomon laser technique, in which selective fetoscopic laser photocoagulation is first performed and then followed by laser of the vascular equator from one side of the placenta to the other, reduces TTTS complications of twin anemia-polycythemia syndrome and recurrent TTTS. The addition of fetal echocardiography to the historical staging of TTTS adds important information that may guide future therapies. The postlaser ablation rate of neurodevelopmental delay in TTTS has recently been reported to be 14%. Cotwin demise is a significant complication of untreated TTTS and survival carries a 25% risk of cystic periventricular leukomalacia, middle cerebral artery infarction, and injury to other central nervous system structures as noted by neuroimaging. SUMMARY Laser therapy for TTTS is clearly the only therapy that halts the disease process, allows both fetuses an opportunity to survive and protects a surviving cotwin in the event of the demise of one twin. Laser techniques have evolved greatly over the last 25 years and recent reports with the addition of the Solomon technique appearing to reduce some postlaser complications (twin anemia-polycythemia sequence and recurrent TTTS). Future focus of TTTS therapy should be centered on understanding the pathophysiology of the disease better with improvement in staging of the disease and on comparison of different laser techniques with the overall goal of not only increasing twin survival rates but also reducing long term neurodevelopmental morbidity.
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Fischbein R, Meeker J, Saling JR, Chyatte M, Nicholas L. Identifying families' shared disease experiences through a qualitative analysis of online twin-to-twin transfusion syndrome stories. BMC Pregnancy Childbirth 2016; 16:163. [PMID: 27422614 PMCID: PMC4946129 DOI: 10.1186/s12884-016-0952-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 07/09/2016] [Indexed: 11/10/2022] Open
Abstract
Background Twin-to-twin transfusion syndrome (TTTS) affects 10–20 % of monochorionic diamniotic (MCDA) births and accounts for 50 % of fetal loss in MCDA pregnancies. This exploratory qualitative study identified shared experiences, including potential emotional and psychosocial impacts, of this serious disease. Methods Forty-five publicly accessible, online stories posted by families who experienced TTTS were analyzed using grounded theory. Results Shared TTTS experiences included a common trajectory: early pregnancy experiences, diagnostic experiences, making decisions, interventions and variable outcomes. Families vacillated between emotional highs such as joy, excitement and relief, and lows including depression, anxiety, anger and grief. Conclusions TTTS disease experience can be considered an “emotional roller coaster” exacerbated by TTTS’s unpredictable and quickly changing nature with the potential for emotional and psychosocial effects. Increased TTTS awareness and research about its corresponding impacts can ensure appropriate patient and family support at all phases of the TTTS experience.
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Affiliation(s)
- Rebecca Fischbein
- Department of Health Policy & Management, College of Public Health, Kent State University, 800 Hilltop Drive, Moulton Hall, P.O. Box 5190, Kent, OH, 44242-0001, USA.
| | - James Meeker
- Northeast Ohio Medical University, 4209 St. Rt. 44, P.O. Box 95, Rootstown, OH, 44272-0095, USA
| | - Julia R Saling
- Northeast Ohio Medical University, 4209 St. Rt. 44, P.O. Box 95, Rootstown, OH, 44272-0095, USA
| | - Michelle Chyatte
- Northeast Ohio Medical University, 4209 St. Rt. 44, P.O. Box 95, Rootstown, OH, 44272-0095, USA
| | - Lauren Nicholas
- D'Youville College, 320 Porter Avenue, Buffalo, NY, 14201, USA
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15
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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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Duryea EL, Happe SK, McIntire DD, Dashe JS. The natural history of twin–twin transfusion syndrome stratified by Quintero stage*. J Matern Fetal Neonatal Med 2016; 29:3411-5. [DOI: 10.3109/14767058.2015.1131263] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Ashwal E, Yinon Y, Fishel-Bartal M, Tsur A, Chayen B, Weisz B, Lipitz S. Twin Anemia-Polycythemia Sequence: Perinatal Management and Outcome. Fetal Diagn Ther 2015; 40:28-34. [DOI: 10.1159/000441451] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 10/01/2015] [Indexed: 11/19/2022]
Abstract
Objective: To determine the perinatal outcome of monochorionic twin pregnancies complicated by twin anemia-polycythemia sequence (TAPS). Methods: All monochorionic twins diagnosed with TAPS between 2011 and 2014 were included. Each twin pair with TAPS (study group) was compared with 2 uncomplicated monochorionic twin pairs who were matched for gestational age at delivery (control group). Neonatal morbidity and mortality were evaluated. Results: During the study period, 179 monochorionic twins were followed at our center, of whom 46 underwent laser ablation due to twin-to-twin transfusion syndrome. TAPS was diagnosed in 10 cases; 8 of them were spontaneous, and 2 occurred following laser surgery. Out of 7 patients diagnosed prenatally with TAPS, 5 cases were managed expectantly, and 2 cases were treated with intrauterine blood transfusion. The rates of severe and mild central nervous system lesions on postnatal ultrasound were similar in the TAPS group and control group (5.0 vs. 2.5%, p = 0.61, and 5.0 vs. 12.5%, p = 0.25, respectively). Additionally, severe neonatal morbidity was comparable between the groups. All neonates were alive at 1 month of age. Conclusion: The neonatal outcome of monocohorionic twins affected by TAPS is favorable and comparable to gestational age-matched uncomplicated monochorionic twins.
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Griffiths PD, Sharrack S, Chan KL, Bamfo J, Williams F, Kilby MD. Fetal brain injury in survivors of twin pregnancies complicated by demise of one twin as assessed byin uteroMR imaging. Prenat Diagn 2015; 35:583-91. [DOI: 10.1002/pd.4577] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Revised: 02/03/2015] [Accepted: 02/09/2015] [Indexed: 11/05/2022]
Affiliation(s)
- P. D. Griffiths
- Academic Unit of Radiology; University of Sheffield; Sheffield UK
| | - S. Sharrack
- Academic Unit of Radiology; University of Sheffield; Sheffield UK
| | - K. L. Chan
- Fetal Medicine Unit; St Mary's Hospital; Manchester UK
| | - J. Bamfo
- Fetal Medicine Unit; St Mary's Hospital; Manchester UK
| | - F. Williams
- Academic Unit of Radiology; University of Sheffield; Sheffield UK
| | - M. D. Kilby
- Birmingham Centre of Women's and Children's Health, College of Medical and Dental Sciences; University of Birmingham; Birmingham UK
- Fetal Medicine Centre, Birmingham Women's Foundation Trust; Birmingham UK
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Gustavo Rencoret P. Embarazo gemelar. REVISTA MÉDICA CLÍNICA LAS CONDES 2014. [DOI: 10.1016/s0716-8640(14)70645-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abstract
In the dominant model, monozygotic (MZ) twinning is universally accepted as a post-fertilization event resulting from splitting of the embryo along its first 2 weeks of development. The stage at which splitting occurs determines chorionicity and amnionicity. A short history on how the model was built is presented, stressing the role played by some embryologists, in particular George Corner, in its completion and final success. Strikingly, for more than 60 years no deep criticisms have been raised against the model, which, in virtue of its rational and plausible character, enjoys the status of undisputed truth. At close examination, the embryological support of the model shows some important weak points, particularly when dealing with late splitting. In the author's view, the model not only has contributed to 'suspend' our knowledge on the timing of MZ twinning, but seems indefensible and claims to be substituted. That factor could imply relevant consequences for embryology and bioethics. As an alternative to the model, a new theory to explain the timing of MZ twinning is proposed. It is based on two premises. First, MZ twinning would be a fertilization event. In that case, due to an alteration of the zygote-blastomere transition, the first zygotic division, instead of producing two blastomeres, generates twin zygotes. Second, monochorionicity and monoamnionicity would not depend on embryo splitting, but on fusion of membranes. Some support for this theory can be found in recent embryological advances and also in some explanations of old.
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Abstract
OBJECTIVE We sought to review the natural history, pathophysiology, diagnosis, and treatment options for twin-twin transfusion syndrome (TTTS). METHODS A systematic review was performed using MEDLINE database, PubMed, EMBASE, and Cochrane Library. The search was restricted to English-language articles published from 1966 through July 2012. Priority was given to articles reporting original research, in particular randomized controlled trials, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Evidence reports and guidelines published by organizations or institutions such as the National Institutes of Health, Agency for Health Research and Quality, American College of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine were also reviewed, and additional studies were located by reviewing bibliographies of identified articles. Consistent with US Preventive Task Force guidelines, references were evaluated for quality based on the highest level of evidence, and recommendations were graded accordingly. RESULTS AND RECOMMENDATIONS TTTS is a serious condition that can complicate 8-10% of twin pregnancies with monochorionic diamniotic (MCDA) placentation. The diagnosis of TTTS requires 2 criteria: (1) the presence of a MCDA pregnancy; and (2) the presence of oligohydramnios (defined as a maximal vertical pocket of <2 cm) in one sac, and of polyhydramnios (a maximal vertical pocket of >8 cm) in the other sac. The Quintero staging system appears to be a useful tool for describing the severity of TTTS in a standardized fashion. Serial sonographic evaluation should be considered for all twins with MCDA placentation, usually beginning at around 16 weeks and continuing about every 2 weeks until delivery. Screening for congenital heart disease is warranted in all monochorionic twins, in particular those complicated by TTTS. Extensive counseling should be provided to patients with pregnancies complicated by TTTS including natural history of the disease, as well as management options and their risks and benefits. The natural history of stage I TTTS is that more than three-fourths of cases remain stable or regress without invasive intervention, with perinatal survival of about 86%. Therefore, many patients with stage I TTTS may often be managed expectantly. The natural history of advanced (eg, stage ≥III) TTTS is bleak, with a reported perinatal loss rate of 70-100%, particularly when it presents <26 weeks. Fetoscopic laser photocoagulation of placental anastomoses is considered by most experts to be the best available approach for stages II, III, and IV TTTS in continuing pregnancies at <26 weeks, but the metaanalysis data show no significant survival benefit, and the long-term neurologic outcomes in the Eurofetus trial were not different than in nonlaser-treated controls. Even laser-treated TTTS is associated with a perinatal mortality rate of 30-50%, and a 5-20% chance of long-term neurologic handicap. Steroids for fetal maturation should be considered at 24 0/7 to 33 6/7 weeks, particularly in pregnancies complicated by stage ≥III TTTS, and those undergoing invasive interventions.
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Abstract
AbstractThe science of genetics is undergoing a paradigm shift. Recent discoveries, including the activity of retrotransposons, the extent of copy number variations, somatic and chromosomal mosaicism, and the nature of the epigenome as a regulator of DNA expressivity, are challenging a series of dogmas concerning the nature of the genome and the relationship between genotype and phenotype. According to three widely held dogmas, DNA is the unchanging template of heredity, is identical in all the cells and tissues of the body, and is the sole agent of inheritance. Rather than being an unchanging template, DNA appears subject to a good deal of environmentally induced change. Instead of identical DNA in all the cells of the body, somatic mosaicism appears to be the normal human condition. And DNA can no longer be considered the sole agent of inheritance. We now know that the epigenome, which regulates gene expressivity, can be inherited via the germline. These developments are particularly significant for behavior genetics for at least three reasons: First, epigenetic regulation, DNA variability, and somatic mosaicism appear to be particularly prevalent in the human brain and probably are involved in much of human behavior; second, they have important implications for the validity of heritability and gene association studies, the methodologies that largely define the discipline of behavior genetics; and third, they appear to play a critical role in development during the perinatal period and, in particular, in enabling phenotypic plasticity in offspring. I examine one of the central claims to emerge from the use of heritability studies in the behavioral sciences, the principle of minimal shared maternal effects, in light of the growing awareness that the maternal perinatal environment is a critical venue for the exercise of adaptive phenotypic plasticity. This consideration has important implications for both developmental and evolutionary biology.
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