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da Silva Rocha J, Guedes-Martins L, Cunha A. Twin Anemia-Polycythemia Sequence (TAPS): From Basic Research to Clinical Practice. Curr Vasc Pharmacol 2023; 21:91-105. [PMID: 36718965 DOI: 10.2174/1570161121666230131112930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/30/2022] [Accepted: 12/30/2022] [Indexed: 02/01/2023]
Abstract
Twin pregnancy is associated with an increased risk of perinatal and maternal complications, and early establishment of the chorionicity type defines this risk. In monochorionic (MC) pregnancies, the fetuses share the same placental mass and exhibit vascular anastomoses crossing the intertwin membrane, and the combination and pattern of anastomoses determine the primary clinical picture and occurrence of future complications. Twin Anemia-Polycythemia Sequence (TAPS) was first described in 2006 after fetoscopic laser surgery in twin-to-twin transfusion syndrome (TTTS) twins, and in 2007, the first spontaneous cases were reported, recognizing TAPS as an individualized vascular identity in fetofetal transfusion syndromes. There are two types of TAPS: spontaneous (3-5%) and iatrogenic or postlaser (2-16%). TAPS consists of small diameter arteriovenous anastomoses (<1 mm) and low-rate, small-caliber AA anastomoses in the absence of amniotic fluid discordances. There are certain antenatal and postnatal diagnostic criteria, which have progressively evolved over time. New, additional secondary markers have been proposed, and their reliability is being studied. The best screening protocol for TAPS in MC twins is still a matter of debate. This review provides a survey of the relevant literature on the epidemiology, vascular pathophysiology, underlying hemodynamic factors that regulate mismatched vascular connections, and diagnostic criteria of this condition. The aim is to increase awareness and knowledge about this recently identified and frequently unrecognized and misdiagnosed pathology.
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Affiliation(s)
- Joana da Silva Rocha
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto 4050-313, Portugal
| | - Luís Guedes-Martins
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto 4050-313, Portugal
- Centro Hospitalar Universitário do Porto EPE, Centro Materno Infantil do Norte, Centro de Medicina Fetal, Serviço de Obstetrícia, Departamento da Mulher e da Medicina Reprodutiva, Largo Prof. Abel Salazar, Porto 4099-001, Portugal
- Unidade de Investigação e Formação - Centro Materno Infantil do Norte, Porto 4099-001, Portugal
- Instituto de Investigação e Inovação em Saúde, Universidade do Porto, 4200-319 Portugal
| | - Ana Cunha
- Centro Hospitalar Universitário do Porto EPE, Centro Materno Infantil do Norte, Centro de Medicina Fetal, Serviço de Obstetrícia, Departamento da Mulher e da Medicina Reprodutiva, Largo Prof. Abel Salazar, Porto 4099-001, Portugal
- Unidade de Investigação e Formação - Centro Materno Infantil do Norte, Porto 4099-001, Portugal
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Baschat AA, Miller JL. Pathophysiology, diagnosis, and management of twin anemia polycythemia sequence in monochorionic multiple gestations. Best Pract Res Clin Obstet Gynaecol 2022; 84:115-126. [PMID: 35450772 DOI: 10.1016/j.bpobgyn.2022.03.012] [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: 02/28/2022] [Accepted: 03/11/2022] [Indexed: 11/02/2022]
Abstract
Twin anemia polycythemia sequence (TAPS) is a consequence of unequal sharing of red blood cells between monochorionic twins resulting in anemia in the donor and polycythemia in the recipient twin. Prenatally TAPS can occur spontaneously or complicate incomplete laser surgery for twin transfusion syndrome. While there may be clinical overlap with twin transfusion syndrome or selective fetal growth restriction, diagnosis relies on Doppler measurement of middle cerebral artery peak systolic velocities. Significantly discordant velocities are diagnostic, while severity staging is based on signs of cardiovascular compromise. Conservative management, fetoscopic laser coagulation, selective twin reduction, fetal blood and exchange transfusion, and delivery may be selected guided by the gestational age of diagnosis, the severity of the condition, the likelihood of success, and the patients' priorities. Prenatal curative treatment that minimizes the risk for prematurity and residual morbidity at birth is most likely to offer the greatest short-term and long-term benefits.
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Affiliation(s)
- Ahmet A Baschat
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, USA.
| | - Jena L Miller
- Johns Hopkins Center for Fetal Therapy, Department of Gynecology & Obstetrics, USA
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Giorgione V, D'antonio F, Manji A, Reed K, Khalil A. Perinatal outcome of pregnancy complicated by twin anemia-polycythemia sequence: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:813-823. [PMID: 33428243 DOI: 10.1002/uog.23585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/18/2020] [Accepted: 12/29/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To report the perinatal outcome of monochorionic diamniotic (MCDA) twin pregnancies complicated by twin anemia-polycythemia sequence (TAPS), according to the type of TAPS (spontaneous or postlaser) and the management option adopted. METHODS MEDLINE, EMBASE and The Cochrane Library databases were searched for studies reporting on the outcome of twin pregnancies complicated by TAPS. Inclusion criteria were non-anomalous MCDA twin pregnancies with a diagnosis of TAPS. The primary outcome was perinatal mortality; secondary outcomes were neonatal morbidity and preterm birth (PTB). The outcomes were stratified according to the type of TAPS (spontaneous or following laser treatment for twin-twin transfusion syndrome) and the management option adopted (expectant, laser surgery, intrauterine transfusion (IUT) or selective reduction (SR)). Random-effects meta-analysis of proportions was used to analyze the data. RESULTS Perinatal outcome was assessed according to whether TAPS occurred spontaneously or after laser treatment in 506 pregnancies (38 studies). Intrauterine death (IUD) occurred in 5.2% (95% CI, 3.6-7.1%) of twins with spontaneous TAPS and in 10.2% (95% CI, 7.4-13.3%) of those with postlaser TAPS, while the corresponding rates of neonatal death were 4.0% (95% CI, 2.6-5.7%) and 9.2% (95% CI, 6.6-12.3%), respectively. Severe neonatal morbidity occurred in 29.3% (95% CI, 25.6-33.1%) of twins after spontaneous TAPS and in 33.3% (95% CI, 17.4-51.8%) after postlaser TAPS, while the corresponding rates of severe neurological morbidity were 4.0% (95% CI, 3.5-5.7%) and 11.1% (95% CI, 6.2-17.2%), respectively. PTB complicated 86.3% (95% CI, 77.2-93.3%) of pregnancies with spontaneous TAPS and all cases with postlaser TAPS (100% (95% CI, 84.3-100%)). Iatrogenic PTB was more frequent than spontaneous PTB in both groups. Perinatal outcome was assessed according to the management option adopted in 417 pregnancies (21 studies). IUD occurred in 9.8% (95% CI, 4.3-17.1%) of twins managed expectantly and in 13.1% (95% CI, 9.2-17.6%), 12.1% (95% CI, 7.7-17.3%) and 7.6% (95% CI, 1.3-18.5%) of those treated with laser surgery, IUT and SR, respectively. Severe neonatal morbidity affected 27.3% (95% CI, 13.6-43.6%) of twins in the expectant-management group, 28.7% (95% CI, 22.7-35.1%) of those in the laser-surgery group, 38.2% (95% CI, 18.3-60.5%) of those in the IUT group and 23.3% (95% CI, 10.5-39.2%) of those in the SR group. PTB complicated 80.4% (95% CI, 59.8-94.8%), 73.4% (95% CI, 48.1-92.3%), 100% (95% CI, 76.5-100%) and 100% (95% CI, 39.8-100%) of pregnancies after expectant management, laser surgery, IUT and SR, respectively. CONCLUSIONS The present meta-analysis provides pooled estimates of the risks of perinatal mortality, neonatal morbidity and PTB in twin pregnancies complicated by TAPS, stratified by the type of TAPS and the management option adopted. Although a direct comparison could not be performed, the results from this systematic review suggest that spontaneous TAPS may have a better prognosis than postlaser TAPS. No differences in terms of mortality and morbidity were observed when comparing different management options for TAPS, although these findings should be interpreted with caution in view of the limitations of the included studies. Individualized prenatal management, taking into account the severity of TAPS and gestational age, is currently the recommended strategy. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- V Giorgione
- Twin Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - F D'antonio
- Center for Fetal Care and High-risk Pregnancy, University of Chieti, Italy
| | - A Manji
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - K Reed
- Twins Trust, Aldershot, UK
| | - A Khalil
- Twin Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
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Complications of Monochorionic Diamniotic Twins: Stepwise Approach for Early Identification, Differential Diagnosis, and Clinical Management. MATERNAL-FETAL MEDICINE 2020. [DOI: 10.1097/fm9.0000000000000076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Nicholas L, Fischbein R, Aultman J, Ernst-Milner S. Dispelling Myths about Antenatal TAPS: A Call for Action for Routine MCA-PSV Doppler Screening in the United States. J Clin Med 2019; 8:jcm8070977. [PMID: 31277521 PMCID: PMC6678166 DOI: 10.3390/jcm8070977] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 06/29/2019] [Accepted: 07/01/2019] [Indexed: 12/28/2022] Open
Abstract
In the United States, routine middle cerebral artery peak systolic velocity (MCA-PSV) Doppler screening for the detection of antenatal twin anemia-polycythemia sequence (TAPS) is not recommended. The current and only national clinical guideline from the highly-influential Society for Maternal-Fetal Medicine states that, “There is no evidence that monitoring for TAPS with MCA PSV Doppler at any time, including > 26 weeks, improves outcomes, so that this additional screening cannot be recommended at this time.” We argue this recommendation has disproportionate influence on patients and the care they are offered and receive. We use current evidence to highlight and dispel pervasive myths surrounding antenatal TAPS and the value of routine MCA-PSV screening. An ethical framework that illustrates the importance of giving patients the opportunity for routine screening is presented. Findings demonstrate that: (1) both spontaneous and post-laser TAPS is a serious, potentially life-threatening complication, (2) treatment for TAPS is effective and includes expectant management, intrauterine transfusion (IUT), or surgery, (3) and routine MCA-PSV, which has satisfactory diagnostic accuracy, is currently the only way to provide early detection of TAPS. We conclude that routine TAPS screening is a medically proven valuable resource that should be offered to patients in need and to the clinicians who are trying to act toward their benefit.
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Affiliation(s)
- Lauren Nicholas
- Department of Social Sciences, D'Youville College, 591 Niagara Street, Buffalo, NY 14201, USA.
| | - Rebecca Fischbein
- Department of Community and Family Medicine, Northeast Ohio Medical University, 4209 State Route 44, PO Box 95, Rootstown, Ohio 44272, USA
| | - Julie Aultman
- Department of Community and Family Medicine, Northeast Ohio Medical University, 4209 State Route 44, PO Box 95, Rootstown, Ohio 44272, USA
| | - Stephanie Ernst-Milner
- Twin Anaemia Polycythemia Sequence (TAPS) Support Group, TAPS Patient Advocate, 1326HS Almere, The Netherlands
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Hill KM, Masoudian P, Fung-Kee-Fung K, El Demellawy D. Intrauterine Interventions for the Treatment of Twin Anemia-Polycythemia Sequence: A Systematic Review. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 41:981-991. [PMID: 31230662 DOI: 10.1016/j.jogc.2018.04.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 04/03/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Twin anemia-polycythemia sequence (TAPS) is a complication of monochorionic, multiple gestation pregnancies in which blood shunting through placental anastomoses results in chronic anemia in one fetus and chronic polycythemia in another. The outcomes of different treatment modalities for TAPS are not well known. OBJECTIVE To determine the outcomes of the intrauterine interventions used to treat TAPS. STUDY DESIGN A systematic literature search of MEDLINE, EMBASE, and CENTRAL was performed in June 2016. Primary outcomes were mortality, morbidity, and adverse perinatal outcomes. Data were summarized in the form of weighted means, and statistical difference was determined. RESULTS Twenty-one articles were identified for inclusion in this review and were composed of 105 cases of TAPS. In the cases presented in the literature, there was no statistically significant difference in mortality, morbidity, or emergent Caesarean section rates between expectant management, intrauterine transfusion (IUT), and laser ablation therapy. Laser ablation therapy and IUT were found to have a significantly lower rate of adverse perinatal outcomes when compared to expectantly managed cases. CONCLUSIONS The literature looking into the treatment of TAPS is very limited, with no randomized controlled trials and only one includable comparative study. Based on the data in the case report and case study literature, there is no mortality difference between any of the treatment modalities. Expectant management may be associated with an increase in adverse perinatal outcomes when compared to laser therapy and IUT. More comparative studies are needed to assist clinicians in adopting an evidence-based approach to the treatment of TAPS.
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Affiliation(s)
- Kevin M Hill
- Faculty of Medicine, University of Ottawa, Ottawa, ON
| | | | - Karen Fung-Kee-Fung
- Faculty of Medicine, University of Ottawa, Ottawa, ON; Department of Obstetrics and Gynecology, The Ottawa Hospital, Ottawa, ON
| | - Dina El Demellawy
- Faculty of Medicine, University of Ottawa, Ottawa, ON; Department of Pediatric Pathology, Children's Hospital of Eastern Ontario, Ottawa, ON.
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Bahtiyar M, Ekmekci E, Demirel E, Irani R, Copel J. In utero Partial Exchange Transfusion Combined with in utero Blood Transfusion for Prenatal Management of Twin Anemia-Polycythemia Sequence. Fetal Diagn Ther 2018. [DOI: 10.1159/000486198] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Prenatal diagnosis of spontaneous twin anemia-polycythemia sequence and postnatal examination of placental vascular anastomoses. Obstet Gynecol Sci 2016; 59:539-543. [PMID: 27896259 PMCID: PMC5120076 DOI: 10.5468/ogs.2016.59.6.539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 06/02/2016] [Accepted: 06/08/2016] [Indexed: 12/01/2022] Open
Abstract
Twin anemia-polycythemia sequence (TAPS) is characterized by a wide discrepancy of hemoglobin between two monochorionic fetuses without sign of twin oligo-polyhydramnios sequence. A primiparous woman with monochorionic diamniotic twin transferred for preterm labor. Ultrasonographic evaluation at 32+3 weeks of gestation revealed increased middle cerebral artery-peak systolic velocity (77.4 cm/sec, 1.69 multiples of median) in donor and decreased in recipient twin (36.4 cm/sec, 0.79 multiples of median), the twin was diagnosed with TAPS. Repeated cesarean section was performed at 32+5 weeks of gestation following preeclampsia and preterm labor. After delivery, TAPS was confirmed through neonatal hematologic examination. There were no signs of acute hemorrhagic shock or brain injury. Placental evaluation via dye infusion and barium angiogram revealed one arterioarterial anastomoses with six arteriovenous anastomoses of placenta. We report a prenatally diagnosed case of spontaneous TAPS with arterioarterial and arteriovenous anastomoses and suggest careful monitoring of monochorionic twin and opinion on placenta vascular architecture.
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Hiersch L, Eitan M, Ashwal E, Weisz B, Chayen B, Lipitz S, Yinon Y. Amniotic fluid discordance in monochorionic diamniotic twin pregnancies is associated with increased risk for twin anemia-polycythemia sequence. Prenat Diagn 2016; 36:1099-1103. [DOI: 10.1002/pd.4939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 09/05/2016] [Accepted: 09/29/2016] [Indexed: 11/12/2022]
Affiliation(s)
- Liran Hiersch
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Mayan Eitan
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Eran Ashwal
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Boaz Weisz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Benny Chayen
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Shlomo Lipitz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Yoav Yinon
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
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Moaddab A, Nassr AA, Espinoza J, Ruano R, Bateni ZH, Shamshirsaz AA, Mandy GT, Welty SE, Erfani H, Popek EJ, Belfort MA, Shamshirsaz AA. Twin anemia polycythemia sequence: a single center experience and literature review. Eur J Obstet Gynecol Reprod Biol 2016; 205:158-64. [DOI: 10.1016/j.ejogrb.2016.08.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 07/23/2016] [Accepted: 08/13/2016] [Indexed: 10/21/2022]
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Fishel-Bartal M, Weisz B, Mazaki-Tovi S, Ashwal E, Chayen B, Lipitz S, Yinon Y. Can middle cerebral artery peak systolic velocity predict polycythemia in monochorionic-diamniotic twins? Evidence from a prospective cohort study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:470-475. [PMID: 26663574 DOI: 10.1002/uog.15838] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Revised: 11/10/2015] [Accepted: 11/20/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE The antenatal diagnosis of twin anemia-polycythemia sequence (TAPS) in monochorionic-diamniotic (MCDA) twin pregnancies is based on elevated peak systolic velocity in the middle cerebral artery (MCA-PSV) in the donor twin and decreased MCA-PSV in the recipient twin. However, the association between these parameters and polycythemia has not yet been established. The aim of this study was to determine whether MCA-PSV can predict polycythemia in MCDA pregnancies. METHODS This was a prospective cohort study of MCDA pregnancies recruited at 14-18 weeks' gestation from a single tertiary care center between January 2011 and June 2014. Fetal MCA Doppler waveforms were recorded every 2 weeks from 18 weeks' gestation until delivery. Only those with an MCA-PSV measurement within 1 week of delivery were included in the analysis. Neonatal hematocrit level was determined in all twins from venous blood obtained within 4 h of delivery. Polycythemia was defined as a hematocrit of > 65%, and anemia as a hematocrit of < 45%. TAPS was diagnosed when an intertwin hemoglobin difference of > 8 g/dL and reticulocyte count ratio of > 1.7 were observed. RESULTS Of 162 MCDA pregnancies followed during the study period, 69 had an MCA-PSV measurement within 1 week of delivery and were included in the study. Twenty-five neonates were diagnosed with polycythemia and nine twin pairs met the criteria for TAPS. In a pooled analysis, MCA-PSV was negatively correlated with neonatal hematocrit (P = 0.017, r = -0.215) and was significantly higher in anemic fetuses than in normal controls (1.15 multiples of the median (MoM) vs 1.02 MoM, respectively; P = 0.001). However, MCA-PSV was similar among polycythemic and normal fetuses (0.95 MoM vs 1.02 MoM, respectively; P = 0.47). Intertwin difference in MCA-PSV (delta MCA-PSV) was positively correlated with intertwin hematocrit difference (P = 0.002, r = 0.394). Moreover, twin pregnancies with an intertwin hematocrit difference of > 24% had a significantly greater delta MCA-PSV than did those with an intertwin hematocrit difference of ≤ 24% (delta MCA-PSV, 19 vs 5 cm/s; P < 0.001). CONCLUSIONS MCA-PSV is not significantly decreased in polycythemic MCDA twins. However, delta MCA-PSV is associated with a large intertwin difference in hematocrit, and its use may be better than conventional methods for the risk assessment of TAPS. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M Fishel-Bartal
- 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
| | - S Mazaki-Tovi
- 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 Chayen
- 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
| | - Y Yinon
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Twin Anemia Polycythemia Sequence: Current Views on Pathogenesis, Diagnostic Criteria, Perinatal Management, and Outcome. Twin Res Hum Genet 2016; 19:222-33. [PMID: 27068715 DOI: 10.1017/thg.2016.18] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Monochorionic twins share a single placenta and are connected with each other through vascular anastomoses. Unbalanced inter-twin blood transfusion may lead to various complications, including twin-to-twin transfusion syndrome (TTTS) and twin anemia polycythemia sequence (TAPS). TAPS was first described less than a decade ago, and the pathogenesis of TAPS results from slow blood transfusion from donor to recipient through a few minuscule vascular anastomoses. This gradually leads to anemia in the donor and polycythemia in the recipient, in the absence of twin oligo-polyhydramnios sequence (TOPS). TAPS may occur spontaneously in 3-5% of monochorionic twins or after laser surgery for TTTS. The prevalence of post-laser TAPS varies from 2% to 16% of TTTS cases, depending on the rate of residual anastomoses. Pre-natal diagnosis of TAPS is currently based on discordant measurements of the middle cerebral artery peak systolic velocity (MCA-PSV; >1.5 multiples of the median [MoM] in donors and 8 g/dL), and at least one of the following: reticulocyte count ratio >1.7 or minuscule placental anastomoses. Management includes expectant management, and intra-uterine blood transfusion (IUT) with or without partial exchange transfusion (PET) or fetoscopic laser surgery. Post-laser TAPS can be prevented by using the Solomon laser surgery technique. Short-term neonatal outcome ranges from isolated inter-twin Hb differences to severe neonatal morbidity and neonatal death. Long-term neonatal outcome in post-laser TAPS is comparable with long-term outcome after treated TTTS. This review summarizes the current knowledge after 10 years of research on the pathogenesis, diagnosis, management, and outcome in TAPS.
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Fetal Intra-Peritoneal Transfusion for the Management of Very Early Spontaneous Twin Anemia-Polycythemia Sequence in an Obese Patient With a Whole Anterior Placenta. Twin Res Hum Genet 2016; 19:154-7. [DOI: 10.1017/thg.2016.13] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Twin anemia-polycythemia sequence (TAPS) is a rare condition in monochorionic twin pregnancies. Small intertwin placental vascular communications allow transfusion, which results in a hemoglobin difference in the twins in the absence of oligohydramnios or polyhydramnios. We report here a case of TAPS diagnosed at 17 weeks’ gestation in an obese patient (BMI 42) with a whole anterior placenta. The only possible treatment at this stage of pregnancy was intra-uterine transfusion (IUT), which was repeated weekly until photocoagulation of placental anastomoses was feasible. Fetoscopic laser surgery is the only curative treatment, but is challenging in TAPS because of the absence of polyhydramnios and the presence of minuscule anastomoses. An anterior placenta and high BMI can make the procedure even more challenging. This case report demonstrates that very early and rapidly progressing TAPS with technically complicated conditions (elevated BMI and anterior placenta) can be successfully managed with IUT until laser procedure is achievable.
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Lucewicz A, Fisher K, Henry A, Welsh AW. Review of the correlation between blood flow velocity and polycythemia in the fetus, neonate and adult: appropriate diagnostic levels need to be determined for twin anemia-polycythemia sequence. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:152-157. [PMID: 25580896 DOI: 10.1002/uog.14782] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 12/01/2014] [Accepted: 01/02/2015] [Indexed: 06/04/2023]
Abstract
Twin anemia-polycythemia sequence (TAPS) is recognized increasingly antenatally by the demonstration of an anemic twin and a polycythemic cotwin using the middle cerebral artery peak systolic velocity (MCA-PSV). While the MCA-PSV has been shown to correlate well with anemia in singleton fetuses, the evidence to support its use to diagnose fetal polycythemia appears to be less clear-cut. We aimed to evaluate fetal, neonatal and adult literature used to support the use of MCA-PSV for the diagnosis of polycythemia. Comprehensive literature searches were performed for ultrasound evidence of polycythemia in the human fetus, neonate and adult using key search terms. Only manuscripts in the English language with an abstract were considered for the review, performed in June 2014. Fifteen manuscripts were found for the human fetus, including 38 cases of TAPS. Nine of these defined fetal polycythemia as MCA-PSV < 0.8 multiples of the median (MoM), five used < 1.0 MoM and one used 0.8-1.0 MoM. Only two studies, involving a total of 15 cases, proposed a diagnostic level, acknowledging false-positive and -negative cases, though neither reported sensitivities or specificities. Six neonatal studies (96 neonates) demonstrated evidence of decreased cerebral velocities in polycythemia and a consequent increase with hemodilution. In the adult, five studies (57 polycythemic adults) demonstrated increased flow or velocity with hemodilution. Neither neonatal nor adult studies conclusively defined levels for screening for polycythemia. Despite widespread adoption of a cut-off of < 0.8 MoM in the published literature for the polycythemic fetus in TAPS, this is based upon minimal evidence, with unknown sensitivity and specificity. We recommend caution in excluding TAPS based purely upon the absence of a reduced MCA-PSV.
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Affiliation(s)
- A Lucewicz
- Department of Obstetrics & Gynaecology, Westmead Hospital, Westmead, NSW, Australia
| | - K Fisher
- Faculty of Medicine, School of Women's & Children's Health, University of New South Wales, Sydney, NSW, Australia
| | - A Henry
- Faculty of Medicine, School of Women's & Children's Health, University of New South Wales, Sydney, NSW, Australia
- Department of Obstetrics and Gynaecology, St George Hospital, Kogarah, NSW, Australia
- Australian Centre for Perinatal Science, University of New South Wales, Randwick, NSW, Australia
- Department of Maternal-Fetal Medicine, Royal Hospital for Women, Randwick, NSW, Australia
| | - A W Welsh
- Faculty of Medicine, School of Women's & Children's Health, University of New South Wales, Sydney, NSW, Australia
- Australian Centre for Perinatal Science, University of New South Wales, Randwick, NSW, Australia
- Department of Maternal-Fetal Medicine, Royal Hospital for Women, Randwick, NSW, Australia
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Myung KD, Lee YK, Ko SY, Shin SM, Chung JH, Hong SR. A Case of Spontaneous Twin Anemia-Polycythemia Sequence. NEONATAL MEDICINE 2016. [DOI: 10.5385/nm.2016.23.3.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Kwan Dae Myung
- Department of Pediatrics, Cheil General Hospital & Women's Health Care Center, Dankook University College of Medicine, Seoul, Korea
| | - Yeon Kyung Lee
- Department of Pediatrics, Cheil General Hospital & Women's Health Care Center, Dankook University College of Medicine, Seoul, Korea
| | - Sun Young Ko
- Department of Pediatrics, Cheil General Hospital & Women's Health Care Center, Dankook University College of Medicine, Seoul, Korea
| | - Son Moon Shin
- Department of Pediatrics, Cheil General Hospital & Women's Health Care Center, Dankook University College of Medicine, Seoul, Korea
| | - Jin Hoon Chung
- Department of Obsterics and Gynecology, Cheil General Hospital & Women's Health Care Center, Dankook University College of Medicine, Seoul, Korea
| | - Sung Ran Hong
- Department of Pathology, Cheil General Hospital & Women's Health Care Center, Dankook University College of Medicine, Seoul, Korea
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16
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Ashwal E, Yinon Y, Fishel-Bartal M, Tsur A, Chayen B, Weisz B, Lipitz S. Twin Anemia-Polycythemia Sequence: Perinatal Management and Outcome. Fetal Diagn Ther 2015; 40:28-34. [DOI: 10.1159/000441451] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 10/01/2015] [Indexed: 11/19/2022]
Abstract
Objective: To determine the perinatal outcome of monochorionic twin pregnancies complicated by twin anemia-polycythemia sequence (TAPS). Methods: All monochorionic twins diagnosed with TAPS between 2011 and 2014 were included. Each twin pair with TAPS (study group) was compared with 2 uncomplicated monochorionic twin pairs who were matched for gestational age at delivery (control group). Neonatal morbidity and mortality were evaluated. Results: During the study period, 179 monochorionic twins were followed at our center, of whom 46 underwent laser ablation due to twin-to-twin transfusion syndrome. TAPS was diagnosed in 10 cases; 8 of them were spontaneous, and 2 occurred following laser surgery. Out of 7 patients diagnosed prenatally with TAPS, 5 cases were managed expectantly, and 2 cases were treated with intrauterine blood transfusion. The rates of severe and mild central nervous system lesions on postnatal ultrasound were similar in the TAPS group and control group (5.0 vs. 2.5%, p = 0.61, and 5.0 vs. 12.5%, p = 0.25, respectively). Additionally, severe neonatal morbidity was comparable between the groups. All neonates were alive at 1 month of age. Conclusion: The neonatal outcome of monocohorionic twins affected by TAPS is favorable and comparable to gestational age-matched uncomplicated monochorionic twins.
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The North American Fetal Therapy Network Consensus Statement: Management of Complicated Monochorionic Gestations. Obstet Gynecol 2015; 126:575-584. [PMID: 26244534 DOI: 10.1097/aog.0000000000000994] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The North American Fetal Therapy Network is a consortium of 30 medical institutions in the United States and Canada with established expertise in fetal therapy and other forms of multidisciplinary care for complex fetal disorders. This publication is the third in a series of articles written by NAFTNet about monochorionic pregnancies. In this article, we provide the general obstetric practitioner with information regarding management options available for complications of monochorionic gestations. This information may be useful for a better understanding of the pathophysiology of the various conditions, for better patient counseling, for timely referral to a regional treatment center, and for ongoing comanagement after treatment.
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Mari G, Norton ME, Stone J, Berghella V, Sciscione AC, Tate D, Schenone MH. Society for Maternal-Fetal Medicine (SMFM) Clinical Guideline #8: the fetus at risk for anemia--diagnosis and management. Am J Obstet Gynecol 2015; 212:697-710. [PMID: 25824811 DOI: 10.1016/j.ajog.2015.01.059] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 01/23/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE We sought to provide evidence-based guidelines for the diagnosis and management of fetal anemia. METHODS A systematic literature review was performed using MEDLINE, PubMed, EMBASE, and the Cochrane Library. The search was restricted to English-language articles published from 1966 through May 2014. Priority was given to articles reporting original research, in particular randomized controlled trials, although review articles and commentaries were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion. Evidence reports and published guidelines were also reviewed, and additional studies were located by reviewing bibliographies of identified articles. GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology was used for defining the strength of recommendations and rating the quality of evidence. Consistent with US Preventive Task Force guidelines, references were evaluated for quality based on the highest level of evidence. RESULTS AND RECOMMENDATIONS We recommend the following: (1) middle cerebral artery peak systolic velocity (MCA-PSV) measured by ultrasound Doppler interrogation be used as the primary technique to detect fetal anemia; (2) amniotic fluid delta OD450 not be used to diagnosis fetal anemia; (3) MCA-PSV assessment be reserved for those patients who are at risk of having an anemic fetus (proper technique for MCA-PSV evaluation includes assessment of the middle cerebral artery close to its origin, ideally at a zero degree angle without angle correction); (4) if a fetus is deemed at significant risk for severe fetal anemia (MCA greater than 1.5 multiples of the median or hydropic), fetal blood sampling be performed with preparation for an intrauterine transfusion, unless the pregnancy is at a gestational age when the risks associated with delivery are considered to be less than those associated with the procedure; (5) if a fetus is deemed at significant risk for severe fetal anemia, the patient be referred to a center with expertise in invasive fetal therapy; (6) MCA-PSV be considered to determine the timing of a second transfusion in fetuses with anemia, and, alternatively, a predicted decline in fetal hemoglobin may be used for timing the second procedure; and (7) pregnancies with a fetus at significant risk for fetal anemia be delivered at 37-38 weeks of gestation unless indications develop prior to this time.
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Sananès N, Veujoz M, Severac F, Barthoulot M, Meyer N, Weingertner AS, Kohler M, Guerra F, Gaudineau A, Nisand I, Favre R. Evaluation of the Utility of in utero Treatment of Twin Anemia-Polycythemia Sequence. Fetal Diagn Ther 2015; 38:170-8. [PMID: 25790745 DOI: 10.1159/000380822] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 02/09/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study is to evaluate the interest in the in utero treatment of twin anemia-polycythemia sequence (TAPS). METHODS The obstetrical and neonatal data on all cases of TAPS followed up in our institution between 2006 and 2013 were reviewed. Statistical analyses were conducted using Bayesian methods. RESULTS Twenty cases of TAPS were included. Laser therapy or intrauterine transfusion (IUT) was performed on the donor twin in 9 cases. Eleven cases were included in the 'nontreated' group (managed expectantly or diagnosed at birth). The gestational age at diagnosis was lower in the group with treated TAPS [difference (diff) = -22.20 days (-57.13, 14.28), probability (Pr) (diff >0) = 10.6%]. The rate of preterm premature rupture of membranes was higher in the group with treated TAPS [diff = 22.5% (-14, 57), Pr (diff >0) = 89%], but overall mortality was similar. The interval between diagnosis and delivery was longer [diff = 44.37 days (9.41, 77.90), Pr (diff >0) = 99.2%], the TAPS resolution rate was higher [diff = 49.9% (12, 81), Pr (diff >0) = 99.4%], and the neonatal transfusion rate was lower [diff = -30.5% (-60, 0), Pr (diff >0) = 2.6%] in the treated group. CONCLUSION In utero treatment for TAPS is associated with a higher resolution rate of TAPS and a longer time between diagnosis and birth, but overall mortality is the same as with expectant management.
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Affiliation(s)
- Nicolas Sananès
- Department of Obstetrics and Gynecology, Strasbourg University Teaching Hospitals, Strasbourg, France
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20
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Veujoz M, Sananès N, Severac F, Meyer N, Weingertner AS, Kohler M, Guerra F, Gaudineau A, Nisand I, Favre R. Evaluation of prenatal and postnatal diagnostic criteria for twin anemia-polycythemia sequence. Prenat Diagn 2015; 35:281-8. [DOI: 10.1002/pd.4545] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 10/30/2014] [Accepted: 12/01/2014] [Indexed: 11/09/2022]
Affiliation(s)
- Marine Veujoz
- Department of Obstetrics and Gynecology; Strasbourg University Teaching Hospital; Strasbourg France
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
| | - Nicolas Sananès
- Department of Obstetrics and Gynecology; Strasbourg University Teaching Hospital; Strasbourg France
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
- INSERM, UMR-S 1121, ‘Biomatériaux et Bioingénierie’; Strasbourg France
| | - François Severac
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
- Department of Public Health; Strasbourg University Teaching Hospital; Strasbourg France
| | - Nicolas Meyer
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
- Department of Public Health; Strasbourg University Teaching Hospital; Strasbourg France
| | - Anne-Sophie Weingertner
- Department of Obstetrics and Gynecology; Strasbourg University Teaching Hospital; Strasbourg France
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
| | - Monique Kohler
- Department of Obstetrics and Gynecology; Strasbourg University Teaching Hospital; Strasbourg France
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
| | - Fernando Guerra
- Department of Obstetrics and Gynecology; Strasbourg University Teaching Hospital; Strasbourg France
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
| | - Adrien Gaudineau
- Department of Obstetrics and Gynecology; Strasbourg University Teaching Hospital; Strasbourg France
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
| | - Israël Nisand
- Department of Obstetrics and Gynecology; Strasbourg University Teaching Hospital; Strasbourg France
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
| | - Romain Favre
- Department of Obstetrics and Gynecology; Strasbourg University Teaching Hospital; Strasbourg France
- Federation of Translational Medicine; Strasbourg University Teaching Hospital; Strasbourg France
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21
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Dichorionic Triamniotic Triplet Pregnancy Complicated by Twin Anemia Polycythemia Sequence: The Place of Fetal Therapy. Twin Res Hum Genet 2014; 17:589-93. [DOI: 10.1017/thg.2014.69] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Monochorionic twins as part of a high order multiple pregnancy can be an unintended consequence of the increasingly common practice of blastocyst transfer for couples requiring in vitro fertilisation (IVF) for infertility. Dichorionic triamniotic (DCTA) triplets is the most common presentation, and these pregnancies are particularly high risk because of the additional risks associated with monochorionicity. Surveillance for twin-to-twin transfusion syndrome, including twin anemia polycythemia sequence, may be more difficult, and any intervention to treat the monochorionic pair needs to balance the proposed benefits against the risks posed to the unaffected singleton. Counseling of families with DCTA triplets is therefore complex. Here, we report a case of DCTA triplets, where the pregnancy was complicated by threatened preterm labour, and twin anemia polycythemia sequence (TAPS) was later diagnosed at 28 weeks. The TAPS was managed with a single intraperitoneal transfusion, enabling safe prolongation of the pregnancy for over 2 weeks until recurrence of TAPS and preterm labour supervened. Postnatal TAPS was confirmed, and all three infants were later discharged home at term corrected age, and were normal at follow-up. This case highlights that in utero therapy has an important role in multiple pregnancies of mixed chorionicity, and can achieve safe prolongation of pregnancy at critical gestations.
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22
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Rossi AC, Prefumo F. Perinatal Outcomes of Twin Anemia–Polycythemia Sequence: A Systematic Review. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2014; 36:701-707. [DOI: 10.1016/s1701-2163(15)30512-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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23
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Lindenburg ITM, van Kamp IL, Oepkes D. Intrauterine blood transfusion: current indications and associated risks. Fetal Diagn Ther 2014; 36:263-71. [PMID: 24903741 DOI: 10.1159/000362812] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 04/09/2014] [Indexed: 11/19/2022]
Abstract
Fetal anemia is a serious complication in pregnancy and associated with perinatal mortality and morbidity. During 25 years of worldwide experience with intravascular intrauterine blood transfusion, a variety of indications have been described. Intrauterine transfusion (IUT) treatment is considered most successful for fetal anemia due to red cell alloimmunization. Moreover, the use of this procedure has also been reported in pregnancies with parvovirus B19 infection, fetomaternal hemorrhage and placental chorioangiomas, for example. This review focuses on the current indications of intrauterine blood transfusions. In addition, we describe the potential complications of IUT treatment.
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Affiliation(s)
- Irene T M Lindenburg
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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24
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Sainz JA, Romero C, García-Mejido J, Soto F, Turmo E. Analysis of middle cerebral artery peak systolic velocity in monochorionic twin pregnancies as a method for identifying spontaneous twin anaemia-polycythaemia sequence. J Matern Fetal Neonatal Med 2013; 27:1174-6. [DOI: 10.3109/14767058.2013.850662] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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25
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Lopriore E, Slaghekke F, Kersbergen KJ, de Vries LS, Drogtrop AP, Middeldorp JM, Oepkes D, Benders MJ. Severe cerebral injury in a recipient with twin anemia-polycythemia sequence. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 41:702-706. [PMID: 23124777 DOI: 10.1002/uog.12337] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/19/2012] [Indexed: 06/01/2023]
Abstract
Twin anemia-polycythemia sequence (TAPS) results from slow intertwin blood transfusion through minuscule placental vascular anastomoses and is characterized by large intertwin hemoglobin differences in the absence of amniotic fluid discordance. The optimal management of TAPS is not clear. We report a case of TAPS detected antenatally by Doppler ultrasound examination at 15 + 6 weeks' gestation. After counseling, the parents opted for expectant management. Regular Doppler measurements were performed and these remained fairly stable. An emergency Cesarean section was performed at 34 + 5 weeks following signs of fetal distress. The donor twin was severely anemic while the recipient twin had severe polycythemia-hyperviscosity syndrome. On day 1, the recipient developed respiratory insufficiency and subclinical status epilepticus. Magnetic resonance imaging showed a total loss of gray-white matter differentiation as a sign of severe diffuse cerebral ischemia and bilateral intra- and extra-axial hemorrhages. There was almost complete lack of arterial and venous cerebral blood flow. On day 3 intensive care treatment was withdrawn in view of the severity of the brain injury. This case report demonstrates that TAPS may lead to severe cerebral injury and fatal outcome in the recipient twin, and highlights the importance of antenatal Doppler ultrasound monitoring and choice of management.
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Affiliation(s)
- E Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
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26
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Placental characteristics in monochorionic twins with spontaneous versus post-laser twin anemia-polycythemia sequence. Placenta 2013; 34:456-9. [DOI: 10.1016/j.placenta.2013.02.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 01/25/2013] [Accepted: 02/14/2013] [Indexed: 11/22/2022]
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27
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Genova L, Slaghekke F, Klumper F, Middeldorp J, Steggerda S, Oepkes D, Lopriore E. Management of Twin Anemia-Polycythemia Sequence Using Intrauterine Blood Transfusion for the Donor and Partial Exchange Transfusion for the Recipient. Fetal Diagn Ther 2013; 34:121-6. [DOI: 10.1159/000346413] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Accepted: 12/10/2012] [Indexed: 11/19/2022]
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Groussolles M, Sartor A, Connan L, Vayssière C. Evolution of middle cerebral artery peak systolic velocity after a successful laser procedure for iatrogenic twin anemia-polycythemia sequence. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 39:354-356. [PMID: 21425195 DOI: 10.1002/uog.8999] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/10/2011] [Indexed: 05/30/2023]
Abstract
We report a case of twin anemia-polycythemia sequence (TAPS) treated by laser at 24 + 5 weeks' gestation, 7 weeks after a first laser procedure for twin-to-twin transfusion syndrome at 16 + 6 weeks. This management led to the birth of two healthy neonates by Cesarean section at 36 weeks. In this case, weekly measurement of the middle cerebral artery peak systolic velocity allowed us to monitor the twins after both laser treatments and, more specifically, to detect TAPS. Following delivery, placental injection showed a minuscule coagulated arteriovenous anastomosis. Intrauterine transfusion is generally chosen to manage TAPS, but the choice of therapy must consider gestational age, technical difficulties and disease severity. The laser procedure cannot be used as a curative treatment for TAPS in all cases. We propose a decisional algorithm to help clinicians select the appropriate treatment.
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Affiliation(s)
- M Groussolles
- Division of Prenatal Diagnosis, Department of Obstetrics and Gynecology, Hôpital Paule de Viguier, Toulouse, France.
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29
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Gratacós E, Ortiz J, Martinez J. A Systematic Approach to the Differential Diagnosis and Management of the Complications of Monochorionic Twin Pregnancies. Fetal Diagn Ther 2012; 32:145-55. [DOI: 10.1159/000342751] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 08/04/2012] [Indexed: 11/19/2022]
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Abstract
PURPOSE OF REVIEW Our goal is to review recent articles that examine the current state of fetal transfusion therapy from technique to education. RECENT FINDINGS Even as technology facilitates physicians' diagnosis and treatment of rare disorders requiring fetal transfusion therapy, longstanding questions remain such as the use of intravascular versus intraperitoneal transfusion sites. However, the recent progress seen with molecular techniques, disease markers, and mathematical models demonstrates that despite unanswered questions, there is much to be hopeful about in improving our understanding of fetal transfusions and their application to a variety of diseases. SUMMARY Systematic and collaborative approaches to studying low-frequency disorders treatable by fetal transfusions are necessary. Continued refinement of techniques should improve the timeliness and accuracy of diagnosis, as well as assist in determining the appropriate timing, site, and duration of treatments.
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31
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Clinical outcome in neonates with twin anemia-polycythemia sequence. Am J Obstet Gynecol 2010; 203:54.e1-5. [PMID: 20417489 DOI: 10.1016/j.ajog.2010.02.032] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2009] [Revised: 10/29/2009] [Accepted: 02/10/2010] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate neonatal outcome of monochorionic twin pregnancies complicated by twin anemia-polycythemia sequence (TAPS). STUDY DESIGN A cohort of consecutive monochorionic twins with TAPS with double survivors was included in the study. Each twin pair with TAPS was compared with 2 monochorionic twin pairs who were unaffected by TAPS or twin-to-twin transfusion syndrome and who were matched for gestational age at birth. Neonatal death, severe morbidity, and cerebral injury were studied. RESULTS We included 19 twin pairs in the TAPS group and 38 control twin pairs. The incidence of neonatal death and severe neonatal morbidity was similar in the TAPS group and control group (3% [1/38] vs 1% [1/76] and 24% [9/38] vs 28% [21/76], respectively). Severe cerebral injury was detected in 1 infant (5%) in the TAPS group and 1 infant (2%) in the control group. CONCLUSION Neonatal mortality and morbidity rates in a select population of TAPS neonates are similar to control neonatal rates.
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32
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Assaf SA, Benirschke K, Chmait RH. Spontaneous twin anemia–polycythemia sequence complicated by recipient placental vascular thrombosis and hydrops fetalis. J Matern Fetal Neonatal Med 2010; 24:549-52. [DOI: 10.3109/14767058.2010.497878] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Current world literature. Curr Opin Obstet Gynecol 2010; 22:166-75. [PMID: 20216348 DOI: 10.1097/gco.0b013e328338c956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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