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Stellon MA, Joshi DS, Beninati M, Antony KM, Bohrer J, Hinshaw JL, Monroe E, Winchester C, Lobeck I. Management of twin reversed arterial perfusion (TRAP) sequence with microwave ablation: A case report and review of the literature. JOURNAL OF CLINICAL ULTRASOUND : JCU 2024. [PMID: 38940580 DOI: 10.1002/jcu.23754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 05/29/2024] [Accepted: 06/09/2024] [Indexed: 06/29/2024]
Abstract
Twin reversed arterial perfusion (TRAP) sequence carries a high mortality risk to the "pump twin." Management involves disrupting blood flow to the acardiac mass. In this case, the pregnant patient presented at 20 weeks 6 days with Stage IIb TRAP Sequence and underwent percutaneous ultrasound-guided microwave ablation (MWA) of the acardiac mass at 21 weeks 0 days. The probe traversed the thorax of the acardiac mass and ablated the confluence of the umbilical vessels. A healthy child was delivered at 33 weeks 5 days gestation. This report demonstrates the utility of MWA in TRAP sequence and describes a novel approach.
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Affiliation(s)
- Michael A Stellon
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Devashish S Joshi
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Michael Beninati
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kathleen M Antony
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Justin Bohrer
- Department of Obstetrics and Gynecology, Gunderson Health System, La Crosse, Wisconsin, USA
| | - J Louis Hinshaw
- Department of Interventional Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Eric Monroe
- Department of Interventional Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Casey Winchester
- Center for Perinatal Care, UnityPoint Health Meriter Hospital, Madison, Wisconsin, USA
| | - Inna Lobeck
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Walasik I, Litwinska M, Janiak K, Szaflik K, Kaczmarek P, Ludwin A, Litwinska E. Outcome of Monochorionic Diamniotic Twins with Twin Reversed Arterial Perfusion Sequence: Interstitial Laser versus Endoscopic Cord Occlusion. J Clin Med 2023; 12:6593. [PMID: 37892732 PMCID: PMC10607863 DOI: 10.3390/jcm12206593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 09/28/2023] [Accepted: 10/03/2023] [Indexed: 10/29/2023] Open
Abstract
Twin reversed arterial perfusion sequence (TRAP) is a rare complication of monochorionic twins (MC). This study aimed to describe and compare the short- and long-term outcomes of MC pregnancies with the TRAP sequence treated with two different techniques: interstitial fetal laser (IFL) (n = 22) versus endoscopic cord occlusion (CO) (n = 24). The study population included 46 MC pregnancies with TRAP. Pregnancy loss within 2 weeks after the procedure occurred in 27% of cases (6/22) in the group treated with IFL and in 8% of cases (2/24) in the group treated with CO. The survival rate of the pump twin was 73% (16/22) in the IFL group and 83% (20/24) in the group treated with CO. The median gestational age at birth was 38 weeks in the group treated with IFL and 35 weeks in the group treated with CO. The rate of preterm birth before 34 weeks was 12.5% (2/16) in the group treated with IFL and 32% (7/22) in the group treated with CO. In the group treated with IFL, there were no cases of neurological disabilities reported by the parents compared to three cases in the CO group. IFL is associated with a higher risk of early pregnancy loss; however, if the pregnancy progresses, it is associated with lower risks of preterm birth and neurological disabilities in the survivors.
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Affiliation(s)
- Izabela Walasik
- I Department of Obstetrics and Gynecology, Medical University of Warsaw, 02-091 Warsaw, Poland; (I.W.); (M.L.); (A.L.)
| | - Magdalena Litwinska
- I Department of Obstetrics and Gynecology, Medical University of Warsaw, 02-091 Warsaw, Poland; (I.W.); (M.L.); (A.L.)
| | - Katarzyna Janiak
- Department of Gynecology, Fertility and Fetal Surgery, Polish Mother’s Memorial Hospital in Lodz, 93-338 Lodz, Poland; (K.J.); (K.S.); (P.K.)
| | - Krzysztof Szaflik
- Department of Gynecology, Fertility and Fetal Surgery, Polish Mother’s Memorial Hospital in Lodz, 93-338 Lodz, Poland; (K.J.); (K.S.); (P.K.)
| | - Piotr Kaczmarek
- Department of Gynecology, Fertility and Fetal Surgery, Polish Mother’s Memorial Hospital in Lodz, 93-338 Lodz, Poland; (K.J.); (K.S.); (P.K.)
| | - Artur Ludwin
- I Department of Obstetrics and Gynecology, Medical University of Warsaw, 02-091 Warsaw, Poland; (I.W.); (M.L.); (A.L.)
| | - Ewelina Litwinska
- I Department of Obstetrics and Gynecology, Medical University of Warsaw, 02-091 Warsaw, Poland; (I.W.); (M.L.); (A.L.)
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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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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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Duci M, Pulvirenti R, Fascetti Leon F, Capolupo I, Veronese P, Gamba P, Tognon C. Anesthesia for fetal operative procedures: A systematic review. FRONTIERS IN PAIN RESEARCH 2022; 3:935427. [PMID: 36246050 PMCID: PMC9554945 DOI: 10.3389/fpain.2022.935427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/24/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe anesthetic management of fetal operative procedures (FOP) is a highly debated topic. Literature on fetal pain perception and response to external stimuli is rapidly expanding. Nonetheless, there is no consensus on the fetal consciousness nor on the instruments to measure pain levels. As a result, no guidelines or clinical recommendations on anesthesia modality during FOP are available. This systematic literature review aimed to collect the available knowledge on the most common fetal interventions, and summarize the reported outcomes for each anesthetic approach. Additional aim was to provide an overall evaluation of the most commonly used anesthetic agents.MethodsTwo systematic literature searches were performed in Embase, Medline, Web of Science Core Collection and Cochrane Central Register of Controlled Trials up to December 2021. To best cover the available evidence, one literature search was mostly focused on fetal surgical procedures; while anesthesia during FOP was the main target for the second search. The following fetal procedures were included: fetal transfusion, laser ablation of placental anastomosis, twin-reversed arterial perfusion treatment, fetoscopic endoluminal tracheal occlusion, thoraco-amniotic shunt, vesico-amniotic shunt, myelomeningocele repair, resection of sacrococcygeal teratoma, ligation of amniotic bands, balloon valvuloplasty/septoplasty, ex-utero intrapartum treatment, and ovarian cyst resection/aspiration. Yielded articles were screened against the same inclusion criteria. Studies reporting anesthesia details and procedures’ outcomes were considered. Descriptive statistical analysis was performed and findings were reported in a narrative manner.ResultsThe literature searches yielded 1,679 articles, with 429 being selected for full-text evaluation. A total of 168 articles were included. Overall, no significant differences were found among procedures performed under maternal anesthesia or maternal-fetal anesthesia. Procedures requiring invasive fetal manipulation resulted to be more effective when performed under maternal anesthesia only. Based on the available data, a wide range of anesthetic agents are currently deployed and no consistency has been found neither between centers nor procedures.ConclusionsThis systematic review shows great variance in the anesthetic management during FOP. Further studies, systematically reporting intraoperative fetal monitoring and fetal hormonal responses to external stimuli, are necessary to identify the best anesthetic approach. Additional investigations on pain pathways and fetal pain perception are advisable.
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Affiliation(s)
- Miriam Duci
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
| | - Rebecca Pulvirenti
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
| | - Francesco Fascetti Leon
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
- Correspondence: Francesco Fascetti Leon
| | - Irma Capolupo
- Department of Medical and Surgical Neonatology, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Paola Veronese
- Maternal-fetal Medicine Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
| | - Piergiorgio Gamba
- Pediatric Surgery Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
| | - Costanza Tognon
- Anesthesiology Pediatric Unit, Department of Women’s and Children’s Health, Padua University Hospital, Padua, Italy
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Donepudi R, Hessami K, Nassr AA, Espinoza J, Sanz Cortes M, Sun L, Shirazi M, Yinon Y, Belfort MA, Shamshirsaz AA. Selective reduction in complicated monochorionic pregnancies: a systematic review and meta-analysis of different techniques. Am J Obstet Gynecol 2022; 226:646-655.e3. [PMID: 34678178 DOI: 10.1016/j.ajog.2021.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/08/2021] [Accepted: 10/10/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE This systematic review and meta-analysis aimed to compare the perinatal outcomes of complicated monochorionic pregnancies after selective reduction by radiofrequency ablation, bipolar cord coagulation, and interstitial laser. DATA SOURCES We searched PubMed, Scopus, and Web of Science, from the inception of the database up to April 26, 2021. STUDY ELIGIBILITY CRITERIA Studies comparing at least 2 selective reduction techniques among complicated monochorionic pregnancies and presenting data on perinatal outcomes, including gestational age at procedure, gestational age at delivery, procedure to delivery interval, preterm premature rupture of membranes, preterm birth, survival rate, and birthweight, were eligible. METHODS The random-effects model was used to pool the mean differences or odds ratios and corresponding 95% confidence intervals. Heterogeneity was assessed using the I2 value. RESULTS A total of 10 studies with 734 cases of fetal reduction met the inclusion criteria, of which 9 studies with 674 fetuses were eligible for quantitative synthesis. In 8 studies that compared radiofrequency ablation with bipolar cord coagulation, radiofrequency ablation was associated with increased procedure to delivery interval (days) (mean difference, 13.42; 95% confidence interval, 1.90-24.94; P=.02; I2=0.0%), decreased preterm birth (odds ratio, 0.50; 95% confidence interval, 0.29-0.85; P=.01; I2=3.0%), and decreased preterm premature rupture of membranes (odds ratio, 0.45; 95% confidence interval, 0.27-0.73; P=.001; I2=0.0%). Radiofrequency ablation and bipolar cord coagulation had comparable survival rates (odds ratio, 0.85; 95% confidence interval, 0.54-1.35; P=.49; I2=0.0%). In 3 studies that compared radiofrequency ablation with interstitial laser, there was no significant difference in gestational age at delivery (P=.07) or survival (P=.15). In 3 studies that compared bipolar cord coagulation with interstitial laser, bipolar cord coagulation was associated with a higher survival rate (odds ratio, 3.21; 95% confidence interval, 1.13-9.10; P=.03; I2=0.0%), but the gestational age at delivery was comparable between groups (P=.16). CONCLUSION This study demonstrated that radiofrequency ablation has a greater procedure to delivery interval and decreased preterm premature rupture of membranes and preterm birth than bipolar cord coagulation. Although there was no difference in gestational age at delivery for either bipolar cord coagulation, radiofrequency ablation, or interstitial laser, survival was higher with bipolar cord coagulation than with interstitial laser.
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Affiliation(s)
- Roopali Donepudi
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX
| | - Kamran Hessami
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX; Department of Obstetrics and Gynecology, Women's Health Hospital, Assiut University, Assiut, Egypt
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX
| | - Magdalena Sanz Cortes
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX
| | - Luming Sun
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Mahboobeh Shirazi
- Maternal, Fetal and Neonatal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Yoav Yinon
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel HaShomer, Israel
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX.
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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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Ichizuka K, Seo K, Izudepski T, Nagatsuka M. High-intensity focused ultrasound for noninvasive fetal therapy. J Med Ultrason (2001) 2022:10.1007/s10396-022-01199-2. [PMID: 35278169 DOI: 10.1007/s10396-022-01199-2] [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: 12/15/2021] [Accepted: 01/27/2022] [Indexed: 10/18/2022]
Abstract
High-intensity focused ultrasound (HIFU) consists of an ultrasonic beam that is focused within the body to induce tissue necrosis through both heat energy and as a result of cavitation, which occurs without damaging any intervening tissues. Therefore, it is possible to cauterize and treat tumors without surgical invasion by administering HIFU irradiation from outside the body. This approach has been clinically applied in various fields in recent years, and fetal therapy is no exception, with several clinical applications reported, mainly in basic experiments. This review summarizes the recent basic and clinical findings focusing on fetal treatment with HIFU.
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Affiliation(s)
- Kiyotake Ichizuka
- Department of Obstetrics and Gynecology, Showa University Northern Yokohama Hospital, Chigasakichuo, Tsuduki-ku, Yokohama City, Kanagawa, 224-8503, Japan.
| | - Kohei Seo
- Department of Obstetrics and Gynecology, Showa University Northern Yokohama Hospital, Chigasakichuo, Tsuduki-ku, Yokohama City, Kanagawa, 224-8503, Japan
| | - Tetsuya Izudepski
- Department of Obstetrics and Gynecology, Showa University Northern Yokohama Hospital, Chigasakichuo, Tsuduki-ku, Yokohama City, Kanagawa, 224-8503, Japan
| | - Masaaki Nagatsuka
- Department of Obstetrics and Gynecology, Showa University Northern Yokohama Hospital, Chigasakichuo, Tsuduki-ku, Yokohama City, Kanagawa, 224-8503, Japan
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Outcome of Monochorionic Pregnancies after Selective Feticide with Bipolar Cord Coagulation: A German Single Center Experience. J Clin Med 2022; 11:jcm11061516. [PMID: 35329841 PMCID: PMC8950483 DOI: 10.3390/jcm11061516] [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: 02/01/2022] [Revised: 03/01/2022] [Accepted: 03/08/2022] [Indexed: 12/04/2022] Open
Abstract
Objectives: To review the outcome of complicated monochorionic pregnancies after fetoscopic selective feticide with bipolar cord coagulation in an experienced German center. Methods: All cases that underwent selective feticide using fetoscopic bipolar umbilical cord occlusion (and simultaneous dissection in monoamniotics) at the University of Bonn in the past 10 years were retrospectively analyzed for antenatal and neonatal course and outcome. An adverse outcome was defined as either intrauterine death (IUD), neonatal death (NND), preterm prelabour rupture of membranes (PPROM), or preterm delivery (PTD) before 32.0 weeks of gestation. Results: We diagnosed 56 monochorionic pregnancies, including 43 diamniotic and 8 monoamniotic twins, as well as 5 triplets, complicated by discordant fetal anomalies (n = 10), selective intrauterine growth restriction (n = 29), twin-to-twin transfusion syndrome (n = 13), twin reversed arterial perfusion sequence (n = 3), or severe early twin anemia polycythemia sequence (n = 1), that underwent fetoscopic selective feticide in the 10 years study period. Selective feticide was performed by bipolar cord coagulation at a median gestational age of 21.2 weeks. PPROM occurred in 11 cases, 7 (12.5%) before 32.0 weeks and 4 (7.1%) between 34.0 and 36.0 weeks, respectively. There were five (8.9%) co-twins IUDs at a median of 2 weeks after the intervention. We observed 12 (21.4%) PTDs before 32.0 weeks of gestation and 2 (3.6%) NNDs. Mean gestational age at delivery was 37.1 weeks, with an overall survival of the co-twin of 87.5%. Conclusion: In experienced hands, fetoscopic selective feticide is an effective treatment in complicated monochorionic pregnancies. By sacrificing a sick fetus that jeopardizes the entire pregnancy, a higher survival rate of the co-twin can be achieved.
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Ozawa K, Wada S, Muromoto J, Sugibayashi R, Wada YS, Ito Y, Sago H. Long-term neurodevelopmental outcomes of the pump twin in twin reversed arterial perfusion sequence treated by radiofrequency ablation. Prenat Diagn 2021; 41:1575-1581. [PMID: 34545602 PMCID: PMC9291518 DOI: 10.1002/pd.6048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/02/2021] [Accepted: 09/11/2021] [Indexed: 11/29/2022]
Abstract
Objectives To assess long‐term neurodevelopmental outcomes in children after radiofrequency ablation (RFA) for twin reversed arterial perfusion (TRAP) sequence. Methods This cross‐sectional study included children who underwent RFA for the TRAP sequence between 2012 and 2018. We assessed neurodevelopment in children using the Kinder Infant Development Scale, a validated questionnaire. The developmental quotient (DQ) assessed in nine subscales was calculated as the developmental age divided by the chronological age. Neurodevelopmental delay (NDD) was defined as a DQ of <70 points. Results In total, 38 children from 37 pregnancies underwent RFA for the TRAP sequence during the study period; 6 fetuses died in utero. We sent the questionnaire to the parents of the 32 surviving children and obtained answers for 27 (84%). The median age at the assessment was 2 years and 5 months old. The median total DQ was 111 (80–150). Most median DQs in the nine subscales were above 70. The incidence of NDD was 0% (0/27). There were no marked differences in DQ by chorionicity. Conclusions Children who survived after RFA for TRAP sequence showed favorable long‐term neurodevelopmental outcomes. Radiofrequency ablation seems to rarely affect fetal neurodevelopment. Pregnant women with TRAP sequence are encouraged to be treated by RFA. What's already known about this topic?Radiofrequency ablation (RFA), which induces the coagulation of tissue, is commonly used to treat twin reversed arterial perfusion (TRAP) sequence because of the minimal invasiveness of the technique. The survival rate of the pump twin of TRAP sequence treated by RFA is more than 80%; however, the long‐term neurodevelopmental outcomes of survivors have rarely been investigated.
What does this study add?Pump twins of TRAP sequence who survived after RFA showed favorable long‐term neurodevelopmental outcomes with a median developmental quotient of more than 100. Radiofrequency ablation in fetal surgery itself seems to rarely affect fetal neurodevelopment.
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Affiliation(s)
- Katsusuke Ozawa
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Seiji Wada
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Jin Muromoto
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Rika Sugibayashi
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yuka Sano Wada
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yushi Ito
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Haruhiko Sago
- Division of Fetal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan.,Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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12
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Bouchghoul H, Benachi A, Senat MV. Prenatal Percutaneous Fetoscopic Laser Photocoagulation of Chorioangioma: Report of Two Cases and Review of the Literature. Fetal Diagn Ther 2021; 48:633-639. [PMID: 34496362 DOI: 10.1159/000517392] [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: 02/03/2021] [Accepted: 05/24/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION In Doppler flow diagnosis of a large placental chorioangioma with vascularization, there may be fetal consequences as cardiac output failure and polyhydramnios. Prenatal percutaneous fetoscopic laser photocoagulation of chorioangioma is a therapeutic option. First, we present 2 cases of chorioangioma treated by fetoscopic laser photocoagulation. Second, we conducted a narrative review to identify all reported cases of chorioangioma treated by fetoscopic laser photocoagulation. CASE PRESENTATION Case 1 presented a chorioangioma measuring 48 × 36 × 42 mm, and the Doppler flow study showed vascularization with a high flow rate. The fetus showed dilatation of the right cardiac chambers, moderate tricuspid insufficiency, normal Doppler indices, and polyhydramnios. Case 2 presented a chorioangioma measuring 58 × 36 × 31 mm associated with polyhydramnios and elevated peak systolic velocity of the middle cerebral artery at 49 cm/s, that is, 1.65 MoM. The procedure was performed at 22+2 and 23+5 WG for both cases. Photocoagulation of the chorioangioma vessels was performed first on the small superficial vessels (capillaries) and then on the feeding vessels (artery first and then vein), until complete cessation of blood flow on ultrasound. Successful devascularization was achieved when flow within the chorioangioma's feeding vessels was no longer visualized on intraoperative ultrasound examination using Doppler flow. The ultrasound follow-up showed complete cessation of blood flow in the chorioangioma, normalization of fetal signs, and normal fetal growth in both cases. In case 1, a 2,350-g boy was delivered vaginally after spontaneous labor at 33+6 WG. In case 2, a 2,700-g boy was delivered vaginally after spontaneous labor at 39+2 WG. Neonatal findings were normal, and the outcome at 1 year was normal for both children. CONCLUSION Prenatal percutaneous fetoscopic laser photocoagulation improves survival in large chorioangioma, despite a risk of fetal death in utero.
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Affiliation(s)
- Hanane Bouchghoul
- Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France.,Department of Gynecology-Obstetrics, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, University Paris Saclay, Le Kremlin-Bicêtre, France
| | - Alexandra Benachi
- Department of Gynecology-Obstetrics, Antoine Béclère Hospital, Assistance Publique-Hôpitaux de Paris, University Paris Saclay, Le Kremlin-Bicêtre, France
| | - Marie-Victoire Senat
- Department of Gynecology-Obstetrics, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, University Paris Saclay, Le Kremlin-Bicêtre, France
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13
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von Kaisenberg C, Klaritsch P, Ochsenbein-Kölble N, Hodel ME, Nothacker M, Hecher K. Screening, Management and Delivery in Twin Pregnancy. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2021; 42:367-378. [PMID: 33017845 DOI: 10.1055/a-1248-8896] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The following AWMF guideline (DGGG/AGG & DEGUM responsible) deals with the diagnosis, screening and management of twins as well as the timing and mode of birth.Twin pregnancies can be classified as dichorionic diamniotic (DC DA), monochorionic diamniotic (MC DA) and monochorionic monoamniotic (MC MA) which are always monochorionic.Twin pregnancies can be concordant (both twins are affected) or discordant (only one twin is affected) for chromosomal defects, malformations, growth restriction and hemodynamic disorders.Chorionicity is the prognostically most significant parameter. Monochorial twins have significantly higher risks of intrauterine morbidity and mortality compared to dichorial twins.In particular, general aspects of twin pregnancies such as dating, determination of chorionicity and amnionicity, the labeling of twin fetuses and the perinatal switch phenomenon are discussed.Routine monitoring of MC and DC twin pregnancies with ultrasound at 11-13+ 6 weeks of gestation for chromosomal defects, invasive prenatal diagnosis, first-trimester NT or CRL discrepancies, early diagnosis of fetal anatomical defects, and management of twins with abnormalities, including selective fetocide, is described.Second trimester screening and management for preterm birth, intrauterine selective growth restriction (sFGR), classification of monochorial twins with sFGR, and management of the surviving twin after the death of the co-twin are described.Complications exclusively affecting MC twins include Twin to Twin Transfusion Syndrome (TTTS) with the important topics screening, prognosis, complications of laser therapy, timing of delivery, risks for brain abnormalities and delayed neurological development, Twin Anemia-Polycythemia Sequence (TAPS) and Twin Reversed Arterial Perfusion (TRAP) Sequence. This also includes MC MA twins as well as conjoined twins.Finally, the birth mode and time for DC and MC twin pregnancies are described.The information is summarized in 62 recommendations for action, 4 tables and 8 illustrations with comprehensive background texts.The guideline is an international guideline adaptation (ISUOG, NICE) as well as a systematic literature search and is up-to-date.
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Affiliation(s)
| | - Philipp Klaritsch
- Department of Obstetrics and Gynecology, Medical University Graz, Austria
| | | | | | - Monika Nothacker
- AWMF-Institut für Medizinisches Wissensmanagement (AWMF-IMWi), University of Marburg, Germany
| | - Kurt Hecher
- Department of Obstetrics and Fetal Medicine, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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14
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Forde B, Habli M. Unique Considerations: Preterm Prelabor Rupture of Membranes in the Setting of Fetal Surgery and Higher Order Pregnancies. Obstet Gynecol Clin North Am 2021; 47:653-669. [PMID: 33121651 DOI: 10.1016/j.ogc.2020.08.008] [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
Two unique aspects of antenatal care occur in the setting of fetal surgery and multiple gestations. As fetal interventions increase, so do the number of cases of iatrogenic preterm prelabor rupture of membranes (PPROM). Because of the amniotic sac's inability to heal, the risk of PPROM after surgery is directly correlated with the number of interventions, the size of the defect, and the surgery performed. Higher order gestations also carry an increased risk of PPROM. This paper reviews the risks and management of PPROM in the setting of the various prenatal interventions as well as in the setting of multiple gestations.
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Affiliation(s)
- Braxton Forde
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Medical Sciences Building, Room 4555, 231 Albert Sabin Way, Cincinnati, OH 45267-0526, USA.
| | - Mounira Habli
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Good Samaritan Hospital, Cincinnati, OH, USA; Fetal Care Center of Cincinnati, Cincinnati Children's Hospital, Cincinnati, OH, USA
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15
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Sharma D, Tsibizova VI. Current perspective and scope of fetal therapy: part 1. J Matern Fetal Neonatal Med 2020; 35:3783-3811. [PMID: 33135508 DOI: 10.1080/14767058.2020.1839880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Fetal therapy term has been described for any therapeutic intervention either invasive or noninvasive for the purpose of correcting or treating any fetal malformation or condition. Fetal therapy is a rapidly evolving specialty and has gained pace in last two decades and now fetal intervention is being tried in many malformations with rate of success varying with the type of different fetal conditions. The advances in imaging techniques have allowed fetal medicine persons to make earlier and accurate diagnosis of numerous fetal anomalies. Still many fetal anomalies are managed postnatally because the fetal outcomes have not changed significantly with the use of fetal therapy and this approach avoids unnecessary maternal risk secondary to inutero intervention. The short-term maternal risk associated with fetal surgery includes preterm labor, premature rupture of membranes, uterine wall bleeding, chorioamniotic separation, placental abruption, chorioamnionitis, and anesthesia risk. Whereas, maternal long-term complications include risk of infertility, uterine rupture, and need for cesarean section in future pregnancies. The decision for invasive fetal therapy should be taken after discussion with parents about the various aspects like postnatal fetal outcome without fetal intervention, possible outcome if the fetal intervention is done, available postnatal intervention for the fetal condition, and possible short-term and long-term maternal complications. The center where fetal intervention is done should have facility of multi-disciplinary team to manage both maternal and fetal complications. The major issues in the development of fetal surgery include selection of patient for intervention, crafting effective fetal surgical skills, requirement of regular fetal and uterine monitoring, effective tocolysis, and minimizing fetal and maternal fetal risks. This review will cover the surgical or invasive aspect of fetal therapy with available evidence and will highlight the progress made in the management of fetal malformations in last two decades.
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Affiliation(s)
- Deepak Sharma
- Department of Neonatology, National Institute of Medical Science, Jaipur, India
| | - Valentina I Tsibizova
- Almazov National Medical Research Centre, Health Ministry of Russian Federation, Saint Petersburg, Russia
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16
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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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17
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Vitucci A, Fichera A, Fratelli N, Sartori E, Prefumo F. Twin Reversed Arterial Perfusion Sequence: Current Treatment Options. Int J Womens Health 2020; 12:435-443. [PMID: 32547251 PMCID: PMC7266514 DOI: 10.2147/ijwh.s214254] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Twin reversed arterial perfusion (TRAP) sequence is a specific and severe complication of monochorionic multiple pregnancy, characterized by vascular anastomosis and partial or complete lack of cardiac development in one twin. Despite its rarity, interest in the international literature is rising, and we aimed to review its pathogenesis, prenatal diagnostic features and treatment options. Due to the parasitic hemodynamic dependence of the acardiac twin on the pump twin, the management of these pregnancies aims to maximize the pump twin's chances of survival. If treatment is needed, the best timing of intervention is still debated, although the latest studies encourage intervention in the first trimester of pregnancy. As for the technique of choice to interrupt the vascular supply to the acardiac twin, ultrasound-guided laser coagulation and radiofrequency ablation of the intrafetal vessels are usually the preferred approaches.
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Affiliation(s)
- Annachiara Vitucci
- Division of Obstetrics and Gynecology, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Anna Fichera
- Division of Obstetrics and Gynecology, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Nicola Fratelli
- Division of Obstetrics and Gynecology, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Enrico Sartori
- Division of Obstetrics and Gynecology, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Federico Prefumo
- Division of Obstetrics and Gynecology, ASST Spedali Civili, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
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18
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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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19
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Abgral M, Victoire Senat M, Houllier M, Bouchghoul H. [How I do… a selective feticide using ultrasound-guided bipolar cord coagulation in a monochorionic pregnancy?]. ACTA ACUST UNITED AC 2020; 48:520-523. [PMID: 31923644 DOI: 10.1016/j.gofs.2020.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Indexed: 11/27/2022]
Affiliation(s)
- M Abgral
- Service de gynécologie obstétrique, hôpital Bicêtre, AP-HP, 78, avenue du Général-Leclerc, 94275 Le Kremlin-Bicêtre cedex, France
| | - M Victoire Senat
- Service de gynécologie obstétrique, hôpital Bicêtre, AP-HP, 78, avenue du Général-Leclerc, 94275 Le Kremlin-Bicêtre cedex, France; Université Paris-Saclay, université Paris-Sud, UVSQ, CESP, Inserm, 94807 Villejuif, France
| | - M Houllier
- Service de gynécologie obstétrique, hôpital Bicêtre, AP-HP, 78, avenue du Général-Leclerc, 94275 Le Kremlin-Bicêtre cedex, France
| | - H Bouchghoul
- Service de gynécologie obstétrique, hôpital Bicêtre, AP-HP, 78, avenue du Général-Leclerc, 94275 Le Kremlin-Bicêtre cedex, France; Université Paris-Saclay, université Paris-Sud, UVSQ, CESP, Inserm, 94807 Villejuif, France.
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20
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Tavares de Sousa M, Glosemeyer P, Diemert A, Bamberg C, Hecher K. First-trimester intervention in twin reversed arterial perfusion sequence. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:47-49. [PMID: 31486133 DOI: 10.1002/uog.20860] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 08/16/2019] [Accepted: 08/20/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To report the outcome of monochorionic twins with twin reversed arterial perfusion (TRAP) sequence following interstitial laser therapy in the first trimester. METHODS This was a retrospective cohort study of all consecutive cases of TRAP that underwent interstitial laser therapy at ≤ 14 + 3 weeks' gestation between January 2014 and April 2016. Interstitial laser treatment was performed under ultrasound guidance using a 400-nm Nd:YAG laser fiber. Hospital records were reviewed to ascertain perinatal survival and morbidity. RESULTS Twelve monochorionic twin pregnancies underwent interstitial laser treatment of the umbilical artery of the acardiac fetus, at a median gestational age of 13 + 5 (interquartile range (IQR), 13 + 4 to 14 + 0) weeks. In all cases, one treatment was sufficient to achieve complete interruption of the perfusion of the acardiac twin. There were no procedure-related complications during or within 48 h after the procedure. In one (8.3%) case, intrauterine death of the pump twin occurred 2 weeks after the intervention. All other cases (91.7%) resulted in a live birth at a median gestational age of 39 + 6 (IQR, 37 + 1 to 41 + 2) weeks and with a median birth weight of 3370 (IQR, 2980-3480) g. No neonatal mortality or serious morbidity occurred. CONCLUSIONS Our results support the use of interstitial laser therapy in the first trimester of pregnancy complicated by TRAP sequence, showing a live birth rate of 92%. The results of a randomized controlled trial, evaluating early vs late intervention in pregnancy with TRAP sequence, are awaited. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- M Tavares de Sousa
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - P Glosemeyer
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A Diemert
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - C Bamberg
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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21
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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: 15] [Impact Index Per Article: 3.0] [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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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: 4] [Impact Index Per Article: 0.7] [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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Glanc P, Nyberg DA, Khati NJ, Deshmukh SP, Dudiak KM, Henrichsen TL, Poder L, Shipp TD, Simpson L, Weber TM, Zelop CM. ACR Appropriateness Criteria ® Multiple Gestations. J Am Coll Radiol 2018; 14:S476-S489. [PMID: 29101986 DOI: 10.1016/j.jacr.2017.08.051] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 12/28/2022]
Abstract
Women with twin or higher-order pregnancies will typically have more ultrasound examinations than women with a singleton pregnancy. Most women will have at minimum a first trimester scan, a nuchal translucency evaluation scan, fetal anatomy scan at 18 to 22 weeks, and one or more scans in the third trimester to evaluate growth. Multiple gestations are at higher risk for preterm delivery, congenital anomalies, fetal growth restriction, placenta previa, vasa previa, and velamentous cord insertion. Chorionicity and amnionicity should be determined as early as possible when a twin pregnancy is identified to permit triage of the monochorionic group into a closer surveillance model. Screening for congenital heart disease is warranted in monochorionic twins because they have an increased rate of congenital cardiac anomalies. In addition, monochorionic twins have a higher risk of developing cardiac abnormalities in later gestation related to right ventricular outflow obstruction, in particular the subgroups with twin-twin transfusion syndrome or selective intrauterine growth restriction. Monochorionic twins have unique complications including twin-to-twin transfusion syndrome, twin embolization syndrome, and acardius, or twin-reversed arterial perfusion sequence. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Phyllis Glanc
- Principal Author and Specialty Chair, Sunnybrook Health Sciences Centre, Bayview Campus, Toronto, Ontario, Canada.
| | - David A Nyberg
- Co-Author, The Old Vicarage, Worcester Park, United Kingdom
| | - Nadia J Khati
- Panel Chair, George Washington University Hospital, Washington, District of Columbia
| | | | | | | | - Liina Poder
- University of California San Francisco, San Francisco, California
| | - Thomas D Shipp
- Brigham & Women's Hospital, Boston, Massachusetts; American College of Obstetrics and Gynecology
| | - Lynn Simpson
- Columbia University Medical Center, New York, New York; American College of Obstetrics and Gynecology
| | | | - Carolyn M Zelop
- Valley Hospital, Ridgewood, New Jersey and NYU School of Medicine, New York, New York; American College of Obstetrics and Gynecology
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Use of the Tei Index in the Conservative Management of TRAP Sequence Pregnancies Diagnosed during the Periviable Period: A Case Series. Case Rep Obstet Gynecol 2018; 2018:2521797. [PMID: 29765784 PMCID: PMC5885347 DOI: 10.1155/2018/2521797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 01/02/2018] [Accepted: 02/06/2018] [Indexed: 11/24/2022] Open
Abstract
Twin Reverse Arterial Perfusion (TRAP) Sequence is a rare complication of monochorionic pregnancies. Without intervention, the viable pump twin in a case of TRAP Sequence may develop high output cardiac failure leading to an intrauterine fetal demise. We present 3 cases of TRAP Sequence pregnancy diagnosed during the second or third trimesters of pregnancy. There are minimal sonographic tools for the guidance of a fetal therapeutic interventional procedure during the second trimester or timing of delivery during the third trimester to reduce morbidity and mortality of a viable fetus. Tei index may be a useful sonographic tool in the management of TRAP Sequence during the second or third trimester of pregnancy.
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Beck MM, Rathore S, Benjamin SJ. Acardiac Twin: A Report of Two Cases. JOURNAL OF FETAL MEDICINE 2017. [DOI: 10.1007/s40556-017-0126-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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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: 19] [Impact Index Per Article: 2.7] [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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SEO K, ICHIZUKA K, OKAI T, NAKAMURA M, HASEGAWA JI, MATSUOKA R, KITADAI Y, SUMIE M, TSUKIMORI K, YOSHIZAWA S, UMEMURA SI, SEKIZAWA A. Evaluation of Second-generation HIFU Systems: Less-invasive Fetal Therapy for TRAP Sequence. ACTA ACUST UNITED AC 2017. [DOI: 10.15369/sujms.29.241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Kohei SEO
- Showa University, School of Medicine, Department of Obstetrics and Gynecology
| | - Kiyotake ICHIZUKA
- Showa University, School of Medicine, Department of Obstetrics and Gynecology
| | - Takashi OKAI
- Aiiku Hospital, Department of Obstetrics and Gynecology
| | - Masamitsu NAKAMURA
- Showa University, School of Medicine, Department of Obstetrics and Gynecology
| | - Jun-ichi HASEGAWA
- St. Marianna University, School of Medicine, Department of Obstetrics and Gynecology
| | - Ryu MATSUOKA
- Showa University, School of Medicine, Department of Obstetrics and Gynecology
| | - Yuzo KITADAI
- Fukuoka Children's Hospital, Department of Obstetrics and Gynecology
| | - Masahiro SUMIE
- Fukuoka Children's Hospital, Department of Obstetrics and Gynecology
| | - Kiyomi TSUKIMORI
- Fukuoka Children's Hospital, Department of Obstetrics and Gynecology
| | - Shin YOSHIZAWA
- Tohoku University, Graduate School of Biomedical Engineering
| | | | - Akihiko SEKIZAWA
- Showa University, School of Medicine, Department of Obstetrics and Gynecology
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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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van Gemert MJ, Ross MG, Nikkels PG, Wijngaard JPVD. Acardiac twin pregnancies part III: Model simulations. ACTA ACUST UNITED AC 2016; 106:1008-1015. [DOI: 10.1002/bdra.23559] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 07/07/2016] [Indexed: 12/18/2022]
Affiliation(s)
- Martin J.C. van Gemert
- Department of Biomedical Engineering & Physics, Academic Medical Center; University of Amsterdam; Amsterdam The Netherlands
| | - Michael G. Ross
- Department of Obstetrics and Gynecology; Harbor UCLA Medical Center; Torrance California
| | - Peter G.J. Nikkels
- Department of Pathology, Wilhelmina Children's Hospital; University Medical Center; Utrecht The Netherlands
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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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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: 28] [Impact Index Per Article: 3.5] [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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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: 11] [Impact Index Per Article: 1.4] [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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Yinon Y, Ashwal E, Weisz B, Chayen B, Schiff E, Lipitz S. Selective reduction in complicated monochorionic twins: prediction of obstetric outcome and comparison of techniques. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:670-677. [PMID: 25867754 DOI: 10.1002/uog.14879] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 04/07/2015] [Accepted: 04/09/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To compare the outcomes of radiofrequency ablation (RFA) and bipolar cord coagulation (BPC) methods for selective feticide in complicated monochorionic (MC) twin gestations and to determine risk factors for adverse pregnancy outcome. METHODS This was a retrospective cohort study of all patients with complicated MC twin pregnancy who underwent selective reduction in a single tertiary care center between 2000 and 2014. We compared the two methods with respect to various demographic, obstetric and perinatal outcome variables. RESULTS Fifty-three selective terminations in complicated MC twin gestations were performed, 36 by RFA and 17 by BPC. Each technique resulted in a similar overall survival rate of the remaining twin (88.9% vs 76.5%, P = 0.25). Likewise, the mean procedure-to-delivery interval, the rate of spontaneous preterm delivery < 37, < 34, < 32 and < 28 weeks and the rate of preterm prelabor rupture of the membranes did not differ between the groups. However, among patients in the BPC group, there was a trend towards earlier gestational age at delivery (31.3 vs 35.0 weeks, P = 0.09) compared with in the RFA group. There was selective reduction by RFA due to selective intrauterine growth restriction (sIUGR) in 19 cases, 17 (89.5%) of which survived perinatally, with delivery at a median gestational age of 37 weeks. There were no significant differences in perinatal outcome, irrespective of whether the procedure was performed pre- or post-viability. All post-viability reductions, most of which were by RFA, resulted in perinatal survival. CONCLUSIONS Perinatal outcome of complicated MC twin gestations undergoing selective feticide seems to be similar regardless of whether termination is by BPC or RFA. Nevertheless, RFA appears to be particularly useful in MC twins complicated by sIUGR and in cases requiring selective reduction beyond the age of viability.
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Affiliation(s)
- Y Yinon
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - E Ashwal
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - B Weisz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - B Chayen
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - E Schiff
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - S Lipitz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Stagnati V, Chalouhi GE, Essaoui M, Giuseppi A, Stirnemann JJ, Le Bidois J, Ville Y. Pulmonary stenosis in complicated monochorionic twin pregnancies: prevalence, management and outcome. Prenat Diagn 2015; 35:1085-92. [DOI: 10.1002/pd.4650] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Revised: 06/06/2015] [Accepted: 07/06/2015] [Indexed: 11/06/2022]
Affiliation(s)
- V. Stagnati
- National Referral Centre for Twin-to-Twin Transfusion Syndrome; Paris-Descartes University, Necker-Enfants-Malades Hospital, APHP; Paris France
- Obstetrics and Fetal Medicine Department; Necker-Enfants-Malades Hospital, APHP, Paris V University; Paris France
- Maternal Fetal Medicine Unit; University of Brescia, Spedali Civili di Brescia; Brescia Italy
| | - G. E. Chalouhi
- National Referral Centre for Twin-to-Twin Transfusion Syndrome; Paris-Descartes University, Necker-Enfants-Malades Hospital, APHP; Paris France
- Obstetrics and Fetal Medicine Department; Necker-Enfants-Malades Hospital, APHP, Paris V University; Paris France
| | - M. Essaoui
- National Referral Centre for Twin-to-Twin Transfusion Syndrome; Paris-Descartes University, Necker-Enfants-Malades Hospital, APHP; Paris France
- Obstetrics and Fetal Medicine Department; Necker-Enfants-Malades Hospital, APHP, Paris V University; Paris France
| | - A. Giuseppi
- Neonatology Department; Necker-Enfants-Malades Hospital, APHP, Paris V University; Paris France
| | - J. J. Stirnemann
- National Referral Centre for Twin-to-Twin Transfusion Syndrome; Paris-Descartes University, Necker-Enfants-Malades Hospital, APHP; Paris France
- Obstetrics and Fetal Medicine Department; Necker-Enfants-Malades Hospital, APHP, Paris V University; Paris France
| | - J. Le Bidois
- Pediatric Cardiology Department; Necker-Enfants-Malades Hospital, APHP, Paris V University; Paris France
| | - Y. Ville
- National Referral Centre for Twin-to-Twin Transfusion Syndrome; Paris-Descartes University, Necker-Enfants-Malades Hospital, APHP; Paris France
- Obstetrics and Fetal Medicine Department; Necker-Enfants-Malades Hospital, APHP, Paris V University; Paris France
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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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38
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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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39
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Shaw CJ, ter Haar GR, Rivens IH, Giussani DA, Lees CC. Pathophysiological mechanisms of high-intensity focused ultrasound-mediated vascular occlusion and relevance to non-invasive fetal surgery. J R Soc Interface 2014; 11:20140029. [PMID: 24671935 PMCID: PMC4006242 DOI: 10.1098/rsif.2014.0029] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 03/06/2014] [Indexed: 12/27/2022] Open
Abstract
High-intensity focused ultrasound (HIFU) is a non-invasive technology, which can be used occlude blood vessels in the body. Both the theory underlying and practical process of blood vessel occlusion are still under development and relatively sparse in vivo experimental and therapeutic data exist. HIFU would however provide an alternative to surgery, particularly in circumstances where serious complications inherent to surgery outweigh the potential benefits. Accordingly, the HIFU technique would be of particular utility for fetal and placental interventions, where open or endoscopic surgery is fraught with difficulty and likelihood of complications including premature delivery. This assumes that HIFU could be shown to safely and effectively occlude blood vessels in utero. To understand these mechanisms more fully, we present a review of relevant cross-specialty literature on the topic of vascular HIFU and suggest an integrative mechanism taking into account clinical, physical and engineering considerations through which HIFU may produce vascular occlusion. This model may aid in the design of HIFU protocols to further develop this area, and might be adapted to provide a non-invasive therapy for conditions in fetal medicine where vascular occlusion is beneficial.
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Affiliation(s)
- C. J. Shaw
- Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0HS, UK
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge CB2 3EG, UK
| | - G. R. ter Haar
- Joint Department of Physics, Institute of Cancer Research: Royal Marsden NHSF Trust, Downs Road, Sutton, Surrey SM2 5PT, UK
| | - I. H. Rivens
- Joint Department of Physics, Institute of Cancer Research: Royal Marsden NHSF Trust, Downs Road, Sutton, Surrey SM2 5PT, UK
| | - D. A. Giussani
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge CB2 3EG, UK
| | - C. C. Lees
- Imperial College London, Hammersmith Campus, Du Cane Road, London W12 0HS, UK
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Campus Gasthuisberg, KU Leuven, Belgium
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40
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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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41
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Nigam A, Agarwal R, Saxena P, Barla J. Acardiac anceps: a rare congenital anomaly. BMJ Case Rep 2014; 2014:bcr-2013-202583. [PMID: 24717594 DOI: 10.1136/bcr-2013-202583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Acardiac twin is a rare congenital anomaly and is exclusively associated with monochorionic twin pregnancies. The abnormalities occur due to abnormal communication between the two fetuses in the form of arterioarterial and venovenous communications, resulting in a grossly abnormal acardiac twin with reduction anomalies mainly of the upper body and gross oedema. Since no two acardiac twins are alike, this case report will add to the acardiac twin anomaly spectrum.
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Affiliation(s)
- Aruna Nigam
- Department of Obstetrics and Gynaecology, Hamdard Institute of Medical Sciences and Research, New Delhi, India
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42
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Berg C, Holst D, Mallmann MR, Gottschalk I, Gembruch U, Geipel A. Early vs late intervention in twin reversed arterial perfusion sequence. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:60-64. [PMID: 23908075 DOI: 10.1002/uog.12578] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/26/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To compare two different management approaches in prenatally diagnosed twin reversed arterial perfusion (TRAP) sequence. METHODS Retrospective analysis of all cases with TRAP sequence diagnosed in one center over a period of 10 years. Prior to 2010, all cases were managed expectantly until 19 weeks' gestation; thereafter, patients could choose either radiofrequency ablation (RFA) or expectant management (Group A). From 2010 onward all patients were offered interstitial laser at the time of diagnosis (12 weeks at the earliest) or expectant management (Group B). RESULTS Forty cases were included in the study. In Group A, 23 cases were diagnosed at a mean gestational age of 19.9 ± 6.3 weeks. Sixteen patients were managed expectantly (13 survivors, 81%), while six underwent RFA at the time of diagnosis and one later in pregnancy (six survivors, 86%). In Group B, 17 cases were diagnosed at a mean gestational age of 16.4 ± 4.7 weeks. Six patients chose expectant management (five survivors, 83%) and 11 had interstitial laser therapy at the time of diagnosis (eight survivors, 73%). The loss rate of the pump twin was not significantly different between Group A and Group B (three of 23 vs four of 17; P = 0.3). In Group B the rates of preterm premature rupture of membranes (PPROM) and delivery < 34 weeks were significantly lower, and gestational age at birth as well as birth weight were significantly higher than in Group A. CONCLUSION Despite the limitations resulting from its retrospective design, our study on management of TRAP sequence adds some evidence in favor of prophylactic intervention by intrafetal laser from 12 weeks onward.
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Affiliation(s)
- C Berg
- Division of Prenatal Medicine and Gynecologic Sonography, Department of Obstetrics and Gynecology, University of Köln, Köln, Germany; Division of Fetal Surgery, Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
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43
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Oruç AS, Mert I, Polat B, Danişman N. A case of acardiac twinning with favourable sonographic signs managed to reach term. J OBSTET GYNAECOL 2013; 34:89. [PMID: 24359063 DOI: 10.3109/01443615.2013.830092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- A S Oruç
- Department of Perinatology, Zekai Tahir Burak Women's Health Education
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44
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Witters I, Coumans A, Willekes C, Fryns JP. Twin reversed arterial perfusion sequence presenting as intrauterine cyst. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 42:724-725. [PMID: 24151135 DOI: 10.1002/uog.13226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 10/16/2013] [Indexed: 06/02/2023]
Affiliation(s)
- I Witters
- Department of Obstetrics and Gynecology, St-Jans Hospital, Genk, Belgium; Maastricht University Medical Centre, GROW School of Oncology and Developmental Biology, Maastricht, The Netherlands; Center for Human Genetics, University of Leuven, Leuven, Belgium
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45
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Van Mieghem T, Hodges R, Jaeggi E, Ryan G. Functional echocardiography in the fetus with non-cardiac disease. Prenat Diagn 2013; 34:23-32. [DOI: 10.1002/pd.4254] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 09/23/2013] [Accepted: 10/07/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Tim Van Mieghem
- Fetal Medicine Unit, Mount Sinai Hospital; University of Toronto; Toronto Canada
| | - Ryan Hodges
- Fetal Medicine Unit, Mount Sinai Hospital; University of Toronto; Toronto Canada
| | - Edgar Jaeggi
- Fetal Cardiac Program, Pediatric Cardiology, Hospital for Sick Children; University of Toronto; Toronto Canada
| | - Greg Ryan
- Fetal Medicine Unit, Mount Sinai Hospital; University of Toronto; Toronto Canada
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46
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Maternal coagulopathy after umbilical cord occlusion for twin reversed arterial perfusion sequence. Obstet Gynecol 2013; 122:498-500. [PMID: 23884274 DOI: 10.1097/aog.0b013e318295c8b9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Twin reversed arterial perfusion sequence is a rare complication of monochorionic twin gestations for which therapy involves the disruption of vascular anastomoses between the pump twin and acardiac twin and death of the acardius. CASE A 37-year-old woman, gravida 11 para 2, with a monochorionic twin pregnancy complicated by twin reversed arterial perfusion sequence who underwent umbilical cord occlusion at 24 weeks of gestation was admitted in preterm labor at 33 weeks of gestation. Maternal disseminated intravascular coagulation (DIC) was diagnosed and her labor was induced. She received multiple blood products to correct her coagulopathy and had an uncomplicated vaginal delivery of the viable pump twin. CONCLUSION Maternal DIC may complicate fetal death after umbilical cord occlusion.
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47
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Okai T, Ichizuka K, Hasegawa J, Matsuoka R, Nakamura M, Shimodaira K, Sekizawa A, Kushima M, Umemura S. First successful case of non-invasive in-utero treatment of twin reversed arterial perfusion sequence by high-intensity focused ultrasound. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 42:112-114. [PMID: 23533101 DOI: 10.1002/uog.12466] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/14/2013] [Indexed: 06/02/2023]
Abstract
High-intensity focused ultrasound (HIFU) has excellent potential as a non-invasive therapeutic tool in various fields of medicine. We present a case of twin reversed arterial perfusion sequence, in which non-invasive blood flow occlusion in the acardiac fetus was successfully achieved by means of HIFU exposure from outside the maternal abdomen. HIFU was applied to blood vessels of the acardiac fetus at the point at which the umbilical cord entered the body in a series of four procedures at 3-day intervals starting at 13 weeks' gestation, and in a final procedure with higher power at 17 weeks. The HIFU intensity was set at approximately 2300 W/cm(2) for the initial series of procedures and at 4600 W/cm(2) for the final procedure, with exposure periods of 10 s. As color Doppler examination revealed absence of blood flow to the acardiac fetus after the second round of HIFU exposure, we concluded that complete occlusion of target vessels had been achieved. Delivery was by Cesarean section at 37 weeks' gestation. A male neonate (the pump fetus) was born weighing 1903 g with Apgar scores of 8 and 9 at 1 and 5 min, respectively. At the time of writing, the baby was healthy and growing normally, with the exception of congenital pseudarthrosis.
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Affiliation(s)
- T Okai
- Department of Obstetrics and Gynecology, School of Medicine, Showa University, Tokyo, Japan
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48
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van den Bos EM, van Klink JMM, Middeldorp JM, Klumper FJ, Oepkes D, Lopriore E. Perinatal outcome after selective feticide in monochorionic twin pregnancies. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 41:653-658. [PMID: 23335029 DOI: 10.1002/uog.12408] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 11/23/2012] [Accepted: 12/06/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To evaluate the incidence and risk factors of adverse perinatal outcome in complicated monochorionic twin pregnancies treated with selective feticide. METHODS This was a retrospective analysis of prospectively collected data from a consecutive, national cohort. All monochorionic twin pregnancies treated with selective feticide at Leiden University Medical Center between June 2000 and November 2011 were included. Obstetric and neonatal data were recorded. The primary outcome measure was adverse perinatal outcome, including fetal or neonatal demise or severe neonatal morbidity. RESULTS Data on perinatal outcome were obtained in all cases (n = 131). Overall perinatal survival rate was 67.2% (88/131). Median gestational age at delivery was 34 (interquartile range, 23-38) weeks. Neonatal mortality and morbidity rate in liveborn children was 4.3% (4/92) and 12.0 % (11/92), respectively. Severe cerebral injury was detected in three children. The overall incidence of adverse perinatal outcome was 41.2% (54/131). Median gestational age at occurrence of preterm prelabor rupture of membranes (PPROM) was 19.0 weeks and 32.0 weeks in cases with and without adverse perinatal outcome, respectively (P = 0.017). Liveborn children with adverse perinatal outcome were born at a lower median gestational age (29.0 weeks) than were children without adverse perinatal outcome (38.0 weeks) (P < 0.001). CONCLUSIONS The risk of adverse perinatal outcome after selective feticide is high and associated with low gestational age at occurrence of PPROM and low gestational age at delivery. Long-term follow-up to assess neurodevelopmental outcome in survivors is required.
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Affiliation(s)
- E M van den Bos
- Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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49
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Weichert A, Kalache K, Hein P, Brauer M, Hinkson L, Henrich W. Radiofrequency ablation as a minimally invasive procedure in the treatment of twin reversed arterial perfusion sequence in twin pregnancy. JOURNAL OF CLINICAL ULTRASOUND : JCU 2013; 41:245-247. [PMID: 22573605 DOI: 10.1002/jcu.21932] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2011] [Accepted: 03/19/2012] [Indexed: 05/31/2023]
Abstract
Twin reversed arterial perfusion sequence is a rare anomaly of monochorionic multiple pregnancies affecting 1 of 35,000 pregnancies and 1% of monochorionic twin pregnancies. In this condition the affected twin has lethal malformations including poor or absent heart development and is reversely perfused by a structurally normal co-twin. We report a case of a 21-year-old woman with a monochorionic twin pregnancy affected by twin reversed arterial perfusion sequence. This case highlights the therapeutic options and the management by radiofrequency ablation, which has been shown to be an easy and reliable technique with a high success rate compared with technically demanding fetoscopic procedures.
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Affiliation(s)
- Alexander Weichert
- Department of Obstetrics, Charité Universitätsmedizin Berlin, Campus Charité Mitte, Charitéplatz 1, 10117 Berlin, Germany
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50
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Vila-Vives JM, Hidalgo-Mora JJ, Perales-Puchalt A, Diago V, Plana A, Perales A. Spontaneous arrest of flow in a TRAP sequence. J OBSTET GYNAECOL 2013; 33:313-4. [PMID: 23550871 DOI: 10.3109/01443615.2012.761182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- J M Vila-Vives
- Department of Obstetrics, La Fe University Hospital, Valencia, USA.
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