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Nicolì P, Damiani GR, Gaetani M, Dellino M, Vitagliano A, Malvasi A, Cazzato G, Cascardi E, Marzullo A, Alfonso R, Cicinelli E, Vimercati A. "The Strange Case of Dr Pump and Mr Acardiac": The Twin Reversed Arterial Perfusion (TRAP) Sequence in Two Monochorionic Monoamniotic (MCMA) Twin Pregnancies-Diagnosis, Prognosis and Management: Review of Literature. Diagnostics (Basel) 2023; 13:3109. [PMID: 37835852 PMCID: PMC10572342 DOI: 10.3390/diagnostics13193109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/22/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
The Twin Reversed Arterial Perfusion (TRAP) Sequence is an extremely rare complication of monochorionic twin pregnancies, with one severely malformed twin (the "acardiac") lacking autonomous placental blood supply and being perfused by the co-twin (the "pump"), through arterio-arterial (and sometimes also veno-venous) vascular anastomoses located on the placental surface. The prognosis is poor: mortality is 100% in the acardiac twin because of its severe malformations and about 50-55% in the pump twin, mainly due to heart failure and prematurity. So, the goal of perinatal management of the TRAP twin pregnancy is to deliver a healthy and near-term pump twin without heart failure or fetal hydrops. Intuitively, the earlier the diagnosis, the better the outcome. Herein, we report two cases of monochorionic monoamniotic (MCMA) twin pregnancies complicated by the TRAP Sequence, which are of interest since the objective of early diagnosis was achieved by means of transvaginal and 3D ultrasound, two techniques which revealed themselves as being useful to this purpose but are underused in the literature. The second aim of this study is to provide an overview of literature data about the diagnosis, prognosis establishment, and management of this rare condition, which are still debated and unclear due to negligible poor-quality evidence.
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Affiliation(s)
- Pierpaolo Nicolì
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Gianluca Raffaello Damiani
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Maria Gaetani
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Miriam Dellino
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Amerigo Vitagliano
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | | | - Gerardo Cazzato
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Eliano Cascardi
- Department of Medical Sciences, University of Turin, 10124 Turin, Italy
- Pathology Unit, FPO-IRCCS Candiolo Cancer Institute, 10060 Candiolo, Italy
| | - Andrea Marzullo
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Raffaello Alfonso
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Ettore Cicinelli
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | - Antonella Vimercati
- Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy
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Vitucci A, Fratelli N, Fichera A, Sartori E, Prefumo F. Timing of intra-fetal laser therapy for twin reversed arterial perfusion (TRAP) sequence: Retrospective series and systematic review and meta-analysis. Int J Gynaecol Obstet 2022; 159:833-840. [PMID: 35435256 PMCID: PMC9790320 DOI: 10.1002/ijgo.14221] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/24/2022] [Accepted: 04/11/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To estimate the neonatal survival rate after intra-fetal laser (IFL) treatment for twin reversed arterial perfusion (TRAP) sequence, and to investigate the effect of gestational age at the time of procedure. METHODS Retrospective cohort study of TRAP sequences followed at our institution from 2013-2020. Systematic review and meta-analysis of the neonatal survival rate after IFL was conducted. Both diamniotic and monoamniotic monochorionic pregnancies were included. A subgroup analysis to compare outcomes according to gestational age at procedure (<16+0 weeks or ≥16+0 weeks) was planned. RESULTS Thirteen pregnancies were followed at our center and seven were treated with IFL: the survival rate was 57%. Ten studies published between 2008 and 2020 for a total of 156 cases were included in the meta-analysis. The overall neonatal survival after IFL was 79% (95% CI 0.72-0.86, I2 22%). A random-effects model comparing neonatal survival for IFL performed <16+0 weeks versus ≥16+0 weeks showed no significant difference between the two groups (OR = 0.93; 95% CI 0.37-2.33). CONCLUSION IFL is a safe and minimally invasive technique for the treatment of TRAP sequence, with a survival rate of 79%. Gestational age at treatment (before or after 16 weeks) does not seem to affect neonatal survival rate.
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Affiliation(s)
- Annachiara Vitucci
- Division of Obstetrics and GynecologyASST Spedali Civili and Department of Clinical and Experimental SciencesUniversity of BresciaBresciaItaly
| | - Nicola Fratelli
- Division of Obstetrics and GynecologyASST Spedali Civili and Department of Clinical and Experimental SciencesUniversity of BresciaBresciaItaly
| | - Anna Fichera
- Division of Obstetrics and GynecologyASST Spedali Civili and Department of Clinical and Experimental SciencesUniversity of BresciaBresciaItaly
| | - Enrico Sartori
- Division of Obstetrics and GynecologyASST Spedali Civili and Department of Clinical and Experimental SciencesUniversity of BresciaBresciaItaly
| | - Federico Prefumo
- Division of Obstetrics and GynecologyASST Spedali Civili and Department of Clinical and Experimental SciencesUniversity of BresciaBresciaItaly
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D'Antonio F, Khalil A. Screening and diagnosis of chromosomal abnormalities in twin pregnancy. Best Pract Res Clin Obstet Gynaecol 2022; 84:229-239. [DOI: 10.1016/j.bpobgyn.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/02/2022] [Indexed: 11/16/2022]
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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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Micheletti T, Eixarch E, Bennasar M, Torres X, Martinez-Crespo JM, Deprest J, Gratacos E. Risk Factors Associated with Preterm Prelabor Rupture of Membranes after Cord Occlusion in Monochorionic Diamniotic Twins. Fetal Diagn Ther 2021; 48:457-463. [PMID: 34130298 DOI: 10.1159/000516513] [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] [Received: 03/07/2021] [Accepted: 04/13/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Preterm prelabor rupture of membranes (PPROM) is a common complication after fetal surgeries. The aim of this study was to assess risk factors for and outcomes after PPROM following cord occlusion (CO) in monochorionic diamniotic (MCDA) pregnancies. METHODS This was a retrospective cohort study of 188 consecutive MCDA pregnancies treated by bipolar or laser CO, either primarily because of discordant malformation (dMF) or severe selective fetal growth restriction (sFGR), or secondarily when complete bichorionization was not possible in case of twin-to-twin transfusion syndrome (TTTS) or sFGR. Intentional septostomy was performed when needed. The procedure-related PPROM was defined as rupture of membranes <32 weeks' gestation (PROM <32 weeks). Selected pre-, intra-, and early postoperative variables were analyzed by univariate and binomial logistic regression to determine they are correlated to PROM <32 weeks after CO. RESULTS Between 2006 and 2017, 188 cases underwent CO. Diagnosis was TTTS in 28.2% (n = 53), severe sFGR in 49.5% (n = 93), and dMF in 22.3% (n = 42). PROM <32 weeks occurred in 21.3% (n = 40), resulting in worse perinatal outcomes, as preterm birth <32 weeks occurred in 80.7% (vs. 8.3%, p = 0.000), procedure-to-delivery interval was 47.5 days (vs. 125, p = 0.000), gestational age (GA) at birth 30.0 weeks (vs. 37.7 weeks, p = 0.000), and survival 65.0% (vs. 91.1%, p = 0.000). In univariate analysis, indication, anterior placenta, cervical length, GA at surgery, operation time, amniodistention and drainage fluid volumes, chorioamniotic membrane separation, and septostomy were selected as relevant factors to be included in the regression model. In a multivariate analysis, TTTS was the only factor associated to PROM <32 weeks (OR 3.5 CI 95% 1.5-7.9). CONCLUSIONS PROM <32 weeks after CO increases the risk of preterm delivery. In this cohort, the membrane rupture was more likely when CO was done in the context of TTTS.
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Affiliation(s)
- Talita Micheletti
- BCNatal Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Elisenda Eixarch
- BCNatal Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centre for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain
| | - Mar Bennasar
- BCNatal Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Ximena Torres
- BCNatal Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Josep Maria Martinez-Crespo
- BCNatal Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Centre for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain
| | - Jan Deprest
- Department of Obstetrics & Gynaecology, Fetal Medicine Unit, UZ Leuven, Leuven, Belgium.,Institute for Women's Health, University College London, London, United Kingdom
| | - Eduard Gratacos
- BCNatal Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centre for Biomedical Research on Rare Diseases (CIBER-ER), Madrid, Spain.,Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain
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Nippita S, Carranza ASO, Paul ME. Funic potassium chloride injection during intact dilation and evacuation. Contraception 2021; 104:275-277. [PMID: 33831443 DOI: 10.1016/j.contraception.2021.03.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 03/26/2021] [Accepted: 03/30/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To describe effectiveness of funic potassium chloride (KCl) injection for fetal demise during intact dilation and evacuation (D&E). STUDY DESIGN We abstracted medical records of patients who underwent standard or intact D&E to identify those who had intact D&E from 20 weeks 0 days through 23 weeks 6 days from February 2016 to August 2017 at one academic center. We extracted data on time to asystole following KCl injection, as well as incidents including hemorrhage, infection, uterine perforation, and unplanned admissions for up to 6 months following each procedure. RESULTS Of 57 procedures, 32 (56%) were intact. Median time from KCl injection to fetal asystole was 48 seconds (interquartile range [IQR] 34-100). Median time to asystole at weeks 20 and 21 (46 seconds [IQR 34-60 seconds]) did not differ significantly from weeks 22 and 23 (85 seconds [IQR 34-200 seconds]), p = 0.15. Asystole occurred in less than four minutes in all cases but one. No adverse events occurred with either the funic KCl injections or the intact D&E procedures. CONCLUSION Funic KCl injection for intact D&E usually causes fetal asystole in less than 4 minutes. IMPLICATIONS Funic KCl injection under direct visualization is a feasible method to induce fetal asystole at the time of intact dilation and evacuation.
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Affiliation(s)
- Siripanth Nippita
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, United States; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, United States
| | | | - Maureen E Paul
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, United States; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA, United States
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Couck I, Ponnet S, Deprest J, Devlieger R, De Catte L, Lewi L. Outcome of monochorionic twin pregnancy with selective fetal growth restriction at 16, 20 or 30 weeks according to new Delphi consensus definition. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:821-830. [PMID: 31945801 DOI: 10.1002/uog.21975] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 12/24/2019] [Accepted: 12/31/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To report the outcome of selective fetal growth restriction (sFGR) diagnosed according to the new Delphi consensus definition, and determine potential predictors of survival, in a cohort of unselected monochorionic diamniotic twin pregnancies. METHODS This was a retrospective study of monochorionic diamniotic twin pregnancies followed from the first trimester onward, which were diagnosed with sFGR at 16, 20 or 30 weeks' gestation. sFGR was defined according to the new Delphi consensus criteria as presence of either an estimated fetal weight (EFW) < 3rd centile in one twin or at least two of the following: EFW of one twin < 10th centile, abdominal circumference of one twin < 10th centile, EFW discordance ≥ 25% or umbilical artery pulsatility index of the smaller twin > 95th centile. The primary outcomes were the overall survival rate (up to day 28 after birth) and risk of loss of one or both twins. We further determined possible predictors of survival using uni- and multivariate generalized estimated equation modeling. RESULTS We analyzed 675 pregnancies, of which 177 (26%) were diagnosed with sFGR at 16, 20 or 30 weeks. The overall survival rate was 313/354 (88%) with 146/177 (82%) pregnancies resulting in survival of both twins, 21/177 (12%) in survival of one twin and 10/177 (6%) in loss of both twins. Subsequent twin anemia-polycythemia sequence (TAPS) developed in 6/177 (3%) and twin-twin transfusion syndrome (TTTS) in 17/177 (10%) pregnancies. All TAPS fetuses survived. The survival rate in sFGR pregnancies that subsequently developed TTTS was 65% (22/34), compared with 91% (279/308) in those with isolated sFGR (no subsequent TAPS or TTTS) (P < 0.001). The majority of sFGR cases were Type I (110/177 (62%)) and had a survival rate of 96% (212/220), as compared with a survival of 55% (12/22) in those with Type-II (P < 0.001) and 83% (55/66) in those with Type-III (P = 0.006) sFGR. The majority of sFGR pregnancies (130/177 (73%)) were first diagnosed at 16 or 20 weeks (early onset), with a survival rate of 85% (221/260), as compared with a survival of 98% (92/94) in sFGR first diagnosed at 30 weeks (late onset) (P = 0.04). A major anomaly in at least one twin was present in 28/177 (16%) sFGR cases. In these pregnancies, survival was 39/56 (70%), compared with 274/298 (92%) in those without an anomaly (P < 0.001). Subsequent development of TTTS (odds ratio (OR), 0.18 (95% CI, 0.06-0.52)), Type-II sFGR (OR, 0.06 (95% CI, 0.02-0.24)) and Type-III sFGR (OR, 0.21 (95% CI, 0.07-0.60)) and presence of a major anomaly in at least one twin (OR, 0.12 (95% CI, 0.04-0.34)), but not gestational age at first diagnosis, were independently associated with decreased survival. CONCLUSIONS Isolated sFGR is associated with a 90% survival rate in monochorionic diamniotic twin pregnancies. The subsequent development of TTTS, absent or reversed end-diastolic flow in the umbilical artery of the smaller twin and the presence of a major anomaly adversely affect survival in sFGR. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- I Couck
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - S Ponnet
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - J Deprest
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Institute for Women's Health, University College London Hospital, London, UK
| | - R Devlieger
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - L De Catte
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - L Lewi
- Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
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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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Valenzuela I, van der Merwe J, De Catte L, Devlieger R, Deprest J, Lewi L. Foetal therapies and their influence on preterm birth. Semin Immunopathol 2020; 42:501-514. [PMID: 32785752 DOI: 10.1007/s00281-020-00811-2] [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] [Received: 06/29/2020] [Accepted: 07/26/2020] [Indexed: 12/12/2022]
Abstract
Foetal therapy aims to improve perinatal survival or to prevent severe long-term handicap. Foetal medicine opens a new territory by treating the foetus as a patient. The mother has nothing to gain in terms of health benefits, yet she is inherently also undergoing treatment. In utero foetal interventions can be divided into ultrasound-guided minimally invasive procedures, fetoscopic procedures and open hysterotomy procedures, which carry an inherent risk of ruptured membranes and preterm birth. In this review, we summarise the conditions that may benefit from foetal therapy and review the current therapies on offer, each with their associated risk of ruptured membrane and preterm birth. We also look into some risk limiting and preventative strategies to mitigate these complications.
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Affiliation(s)
- Ignacio Valenzuela
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium
| | - Johannes van der Merwe
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Luc De Catte
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Roland Devlieger
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium.,Institute for Women's Health, University College London, London, United Kingdom
| | - Liesbeth Lewi
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium. .,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium.
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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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11
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Murgano D, Khalil A, Prefumo F, Mieghem TV, Rizzo G, Heyborne KD, Melchiorre K, Peeters S, Lewi L, Familiari A, Lopriore E, Oepkes D, Murata M, Anselem O, Buca D, Liberati M, Hack K, Nappi L, Baxi LV, Scambia G, Acharya G, D'antonio F. Outcome of twin-to-twin transfusion syndrome in monochorionic monoamniotic twin pregnancy: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:310-317. [PMID: 31595578 DOI: 10.1002/uog.21889] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 08/15/2019] [Accepted: 09/18/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To explore the outcome of monochorionic monoamniotic (MCMA) twin pregnancies affected by twin-to-twin transfusion syndrome (TTTS). METHODS MEDLINE and EMBASE databases were searched for studies reporting the outcome of MCMA twin pregnancies complicated by TTTS. The primary outcome was intrauterine death (IUD); secondary outcomes were miscarriage, single IUD, double IUD, neonatal death (NND), perinatal death (PND), survival of at least one twin, survival of both twins and preterm birth (PTB) before 32 weeks' gestation. Outcomes were assessed in MCMA twins affected by TTTS not undergoing intervention and in those treated with amniodrainage, laser therapy or cord occlusion. Subgroup analysis was performed including cases diagnosed before 24 weeks. Random-effects meta-analysis of proportions was used to analyze the data. RESULTS Fifteen cohort studies, including 888 MCMA twin pregnancies, of which 44 were affected by TTTS, were included in the review. There was no randomized trial comparing the different management options in MCMA twin pregnancies complicated by TTTS. In cases not undergoing intervention, miscarriage occurred in 11.0% of fetuses, while the incidence of IUD, NND and PND was 25.2%, 12.2% and 31.2%, respectively. PTB complicated 50.5% of these pregnancies. In cases treated by laser surgery, the incidence of miscarriage, IUD, NND and PND was 19.6%, 27.4%, 7.4% and 35.9%, respectively, and the incidence of PTB before 32 weeks' gestation was 64.9%. In cases treated with amniodrainage, the incidence of IUD, NND and PND was 31.3%, 13.5% and 45.7% respectively, and PTB complicated 76.2% of these pregnancies. Analysis of cases undergoing cord occlusion was affected by the very small number of included cases. Miscarriage occurred in 19.2%, while there was no case of IUD or NND of the surviving twin. PTB before 32 weeks occurred in 50.0% of these cases. CONCLUSIONS MCMA twin pregnancies complicated by TTTS are at high risk of perinatal mortality and PTB. Further studies are needed in order to elucidate the optimal type of prenatal treatment in these pregnancies. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- D Murgano
- Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK; and Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - F Prefumo
- Department of Obstetrics and Gynecology, Spedali Riunit, Brescia, Italy
| | - T Van Mieghem
- Department of Obstetrics and Gynecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - G Rizzo
- Division of Maternal and Fetal Medicine, Ospedale Cristo Re, University of Rome Tor Vergata, Rome, Italy
| | - K D Heyborne
- Department of Obstetrics and Gynecology, Denver Health and Hospital Authority, Denver, CO, USA; Department of Obstetrics and Gynecology, University of Colorado Denver, Aurora, CO, USA
| | - K Melchiorre
- Department of Obstetrics and Gynecology, 'Spirito Santo' Hospital, Pescara, Italy
| | - S Peeters
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals of KU Leuven, Leuven, Belgium
| | - A Familiari
- Department of Obstetrics and Gynecology, Fondazione IRCCS, Ca Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - E Lopriore
- Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - D Oepkes
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - M Murata
- Center for Maternal, Fetal and Neonatal Medicine, Fukuoka University Hospital, Fukuoka, Japan
| | - O Anselem
- Maternité Port-Royal, Groupe Hospitalier Cochin-Broca-Hôtel-Dieu, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - D Buca
- Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - M Liberati
- Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - K Hack
- Department of Obstetrics and Gynecology, Gelre Hospitals, Apeldoorn, The Netherlands
| | - L Nappi
- Department of Obstetrics and Gynecology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - L V Baxi
- School of Medicine, Columbia University, New York, USA
| | - G Scambia
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Fondazione Policlinico A. Gemelli, Rome, Italy
| | - G Acharya
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Center for Fetal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - F D'antonio
- Department of Obstetrics and Gynecology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
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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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Major Discordant Structural Anomalies in Monochorionic Twins: Spectrum and Outcomes. Twin Res Hum Genet 2018; 21:546-555. [PMID: 30375322 DOI: 10.1017/thg.2018.58] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Monochorionic twins, resulting from a single fertilized egg giving rise to two separate embryos, are monozygotic and considered genetically identical. However, discordant phenotypes have been reported in monozygotic twins. We analyzed a retrospective cohort of 155 monochorionic pregnancies (312 twins) with major discordant structural anomalies coded by the ICD-10 system in order to describe the spectrum of anomalies, the management of the pregnancies, and the perinatal outcome. Treatment options included conservative management, selective feticide with bipolar cord coagulation, or complete termination. All survivors underwent at least 24 months of postnatal follow-up. Discordancy was complicated by twin-to-twin transfusion syndrome in eight pregnancies (5%) and by selective intrauterine growth restriction in 41 (26%). Major structural anomalies affected one system in 139 cases (90%) and multiple systems in 16 (10%). Median gestational age at diagnosis was 19.1 weeks (IQR 16.4-21.3). The most frequent single-system anomalies involved the nervous and circulatory systems. In total, 72 anomalous twins (46%) and 116 normal co-twins (74%) were delivered at a median gestational age of 34.6 weeks (IQR 31.0-36.3). Neonatal/infant death of the anomalous twin occurred in 22 cases (14%), with an overall survival rate of 32% (50/155). Surviving anomalous twins underwent major surgery in 22/50 cases (44%), four of whom (8%) now suffer from severe neurologic morbidity. This study shows that a wide spectrum of major discordant structural anomalies can be found in monochorionic pregnancies. The outcome for the anomalous twin is poor, while the survival rate for the normal co-twin was 71%, with a favorable overall prognosis.
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14
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Abstract
Monoamniotic twins comprise a rare but important subset of twins at risk of unique and serious complications, placing them at the highest risk of perinatal mortality of all twin gestations. In addition to risks faced by all twins (prematurity, selective growth restriction), all monochorionic twins (twin-twin transfusion syndrome), and all monozygotic twins (congenital anomalies), monoamniotic twins face the unique risk of cord entanglement. Accordingly, early diagnosis, screening for fetal anomalies, surveillance for twin-twin transfusion syndrome, decisions related to monitoring after viability, and timing and route of delivery are all critical. Herein, we present recommendations for optimal 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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16
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Ortiz JU, Eixarch E, Peguero A, Lobmaier SM, Bennasar M, Martinez JM, Gratacós E. Chorioamniotic membrane separation after fetoscopy in monochorionic twin pregnancy: incidence and impact on perinatal outcome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:345-349. [PMID: 26148097 DOI: 10.1002/uog.14936] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Revised: 05/10/2015] [Accepted: 06/19/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To evaluate the incidence of chorioamniotic membrane separation (CMS) after fetoscopy in monochorionic diamniotic (MCDA) twins and its impact on pregnancy outcome. METHODS The study group comprised a consecutive series of 338 women with an MCDA pregnancy complicated by twin-twin transfusion syndrome (TTTS) or selective intrauterine growth restriction (sIUGR) treated with selective laser photocoagulation of communicating vessels (SLPCV) or cord occlusion (CO). Data obtained included cervical length, gestational age at procedure, type and duration of surgery and placental location. The incidence of CMS, the rates of miscarriage and preterm prelabor rupture of membranes (PPROM), gestational age at delivery and neonatal survival were recorded. RESULTS Of the study population of MCDA pregnancies, 270 (79.9%) had TTTS and 68 (20.1%) had sIUGR. SLPCV was performed in 252 (74.6%) cases and CO in 86 (25.4%). Postoperative CMS was observed in 70 (20.7%) cases. Patients with CMS had higher rates of miscarriage (14.3% vs 7.1%; P = 0.049), PPROM before 32 weeks (43.3% vs 13.7%; P < 0.001) and preterm delivery before 32 weeks (53.3% vs 26.1%; P < 0.001) and a lower rate of neonatal survival of at least one twin (81.7% vs 93.6%; P = 0.003). Multivariate analysis showed that gestational age at surgery was the only independent predictor, with the highest proportion of CMS occurring in cases that underwent surgery before 18 weeks' gestation (odds ratio, 2.941 (95% CI, 1.640-5.275); P < 0.001). There was no influence of cervical length, placental location, duration of surgery or type of surgery on the risk of CMS. CONCLUSIONS CMS complicated one-fifth of all MCDA pregnancies that underwent fetoscopy. It appeared to be more common in those who underwent surgery before 18 weeks' gestation and was associated with poorer outcomes. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- J U Ortiz
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
- Frauenklinik und Poliklinik, Technische Universität München, Munich, Germany
| | - E Eixarch
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - A Peguero
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - S M Lobmaier
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
- Frauenklinik und Poliklinik, Technische Universität München, Munich, Germany
| | - M Bennasar
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - J M Martinez
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - E Gratacós
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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17
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Khalil A, Rodgers M, Baschat A, Bhide A, Gratacos E, Hecher K, Kilby MD, Lewi L, Nicolaides KH, Oepkes D, Raine-Fenning N, Reed K, Salomon LJ, Sotiriadis A, Thilaganathan B, Ville Y. ISUOG Practice Guidelines: role of ultrasound in twin pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:247-63. [PMID: 26577371 DOI: 10.1002/uog.15821] [Citation(s) in RCA: 351] [Impact Index Per Article: 43.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 11/16/2015] [Indexed: 05/27/2023]
Affiliation(s)
- A Khalil
- Fetal Medicine Unit, St George’s Hospital, St George’s University of London, London, UK
| | - M Rodgers
- The Johns Hopkins Center for Fetal Therapy, Baltimore, MD, USA
| | - A Baschat
- The Johns Hopkins Center for Fetal Therapy, Baltimore, MD, USA
| | - A Bhide
- Fetal Medicine Unit, St George’s Hospital, St George’s University of London, London, UK
| | - E Gratacos
- Fetal Medicine Units and Departments of Obstetrics, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - K Hecher
- Department of Obstetrics and Fetal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germaniy
| | - M D Kilby
- Centre for Women’s and Children's Health, University of Birmingham and Fetal Medicine Centre, Birmingham Women’s Foundation Trust, Birmingham, UK
| | - L Lewi
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King’s College Hospital, London, UK
| | - D Oepkes
- Division of Fetal Medicine, Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - N Raine-Fenning
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
| | - K Reed
- Twin and Multiple Births Association (TAMBA)
| | - L J Salomon
- Hopital Necker-Enfants Malades, AP-HP, Universit´e Paris Descartes, Paris, France
| | - A Sotiriadis
- Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - B Thilaganathan
- Fetal Medicine Unit, St George’s Hospital, St George’s University of London, London, UK
| | - Y Ville
- Hospital Necker-Enfants Malades, AP-HP, Université Paris Descartes, Paris, France
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18
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Parra-Cordero M, Bennasar M, Martínez JM, Eixarch E, Torres X, Gratacós E. Cord Occlusion in Monochorionic Twins with Early Selective Intrauterine Growth Restriction and Abnormal Umbilical Artery Doppler: A Consecutive Series of 90 Cases. Fetal Diagn Ther 2015; 39:186-91. [DOI: 10.1159/000439023] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 06/10/2015] [Indexed: 11/19/2022]
Abstract
Objective: To describe perinatal outcomes achieved with cord occlusion (CO) in monochorionic twins with severe selective intrauterine growth restriction (sIUGR) and abnormal umbilical artery Doppler in the IUGR twin (types II and III). Methods: We studied a consecutive series of 90 cases of sIUGR with abnormal Doppler treated with CO of the IUGR fetus. Abnormal Doppler was defined as continuous (type II, n = 41) or intermittent (type III, n = 49) absent/reversed end-diastolic flow. All cases presented at least one of the following severity criteria: gestational age (GA) <22 weeks, inter-twin estimated weight discordance >35%, reversed end-diastolic umbilical artery flow or ductus venosus pulsatility index >95th centile. We prospectively recorded pregnancy course and perinatal outcome. Results: Median GA at surgery was 20.6 weeks and mean duration 22.4 min. Miscarriage (<24 weeks) occurred in 3.3% (3/90) and preterm delivery <32 weeks in 7.1% (6/84) of continuing pregnancies. GA at delivery was 36.4 weeks and neonatal survival of the larger twin was achieved in 93.3%. Conclusion: In a consecutive series studied by an experienced team, CO in monochorionic twins with severe sIUGR type II or III was associated with delivery >32 weeks in 92.9% and neonatal survival of the normal twin in 93.3% of pregnancies.
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19
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Kunzier NB, Allaf B, Chavez MR, Abenanti-Richmond D, Vintzileos AM. Disentanglement of Discordant Monochorionic-Monoamniotic Twins in a Triplet Pregnancy: An Innovative Approach Utilizing Fetoscopic Laser Coagulation with Micro-Laparoscopic Scissor Dissection. Fetal Diagn Ther 2015. [PMID: 26202082 DOI: 10.1159/000436961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Triplet gestations are associated with high perinatal morbidity. Dichorionic-diamniotic triplet pregnancies with growth discordance, polyhydramnios and structural anomalies carry a significantly increased risk of fetal morbidity and mortality from the baseline risks of high-order multiple pregnancies. Intrauterine fetal death of one fetus of a monochorionic pregnancy may cause neurological injury to the surviving fetus. We present a case where an innovative technique was created combining use of the fetoscopic laser and miniature laparoscopic instruments to selectively reduce and disentangle the umbilical cord of the acranial growth-restricted fetus from the structurally normal fetus's umbilical cord in a dichorionic-diamniotic triplet pregnancy.
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Affiliation(s)
- Nadia B Kunzier
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Winthrop University Hospital, Mineola, N.Y., USA
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20
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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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21
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Molina FS, Gomez LF, Gonzalía DA, Fresneda MD, Padilla MC, Lewi L. Cord transection in monoamniotic twins: use of a 1000-micron fiber with conical tip. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:116-118. [PMID: 24493175 DOI: 10.1002/uog.13316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Revised: 01/09/2014] [Accepted: 01/16/2014] [Indexed: 06/03/2023]
Affiliation(s)
- F S Molina
- Feto-maternal Medicine Unit, Department of Obstetrics and Gynaecology, San Cecilio University Hospital (HUSC), Granada, Spain
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Peeters SH, Devlieger R, Middeldorp JM, DeKoninck P, Deprest J, Lopriore E, Lewi L, Klumper FJ, Kontopoulos E, Quintero R, Oepkes D. Fetal surgery in complicated monoamniotic pregnancies: case series and systematic review of the literature. Prenat Diagn 2014; 34:586-91. [DOI: 10.1002/pd.4353] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 02/28/2014] [Accepted: 02/28/2014] [Indexed: 11/10/2022]
Affiliation(s)
| | - Roland Devlieger
- Department of Obstetrics and Gynecology; University hospitals of KU Leuven; Leuven Belgium
| | | | - Philip DeKoninck
- Department of Obstetrics and Gynecology; University hospitals of KU Leuven; Leuven Belgium
| | - Jan Deprest
- Department of Obstetrics and Gynecology; University hospitals of KU Leuven; Leuven Belgium
| | - Enrico Lopriore
- Department of Pediatrics, Division of Neonatology; Leiden University Medical Center; Leiden The Netherlands
| | - Liesbeth Lewi
- Department of Obstetrics and Gynecology; University hospitals of KU Leuven; Leuven Belgium
| | - Frans J. Klumper
- Department of Obstetrics; Leiden University Medical Center; Leiden The Netherlands
| | | | - Ruben Quintero
- Jackson Fetal Therapy Institute; Jackson Memorial Hospital; Miami FL USA
| | - Dick Oepkes
- Department of Obstetrics; Leiden University Medical Center; Leiden The Netherlands
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23
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Prefumo F, Fichera A, Zanardini C, Frusca T. Fetoscopic cord transection for treatment of monoamniotic twin reversed arterial perfusion sequence. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:234-235. [PMID: 24151190 DOI: 10.1002/uog.13229] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- F Prefumo
- Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynaecology, University of Brescia, Brescia, Italy
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Legendre CM, Moutel G, Drouin R, Favre R, Bouffard C. Differences between selective termination of pregnancy and fetal reduction in multiple pregnancy: a narrative review. Reprod Biomed Online 2013; 26:542-54. [PMID: 23518032 DOI: 10.1016/j.rbmo.2013.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 01/31/2013] [Accepted: 02/05/2013] [Indexed: 10/27/2022]
Abstract
Although selective termination of pregnancy and fetal reduction in multiple pregnancy both involve the termination in utero of the development of live fetuses, these two procedures are different in several aspects. Nevertheless, several authors tend to amalgamate and confuse their psychosocial consequences and the ethical issues they raise. Therefore, this narrative review, derived from a comparative analysis of 91 articles, shines a light on these amalgamations and confusions, as well as on the medical, contextual, experiential and ethical differences specific to selective termination and fetal reduction.
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Affiliation(s)
- Claire-Marie Legendre
- Division of Genetics, Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12e Avenue Nord, Sherbrooke, Québec, Canada
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Lewi L, Deprest J, Hecher K. The vascular anastomoses in monochorionic twin pregnancies and their clinical consequences. Am J Obstet Gynecol 2013; 208:19-30. [PMID: 23103301 DOI: 10.1016/j.ajog.2012.09.025] [Citation(s) in RCA: 162] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 09/10/2012] [Accepted: 09/21/2012] [Indexed: 11/18/2022]
Abstract
Monochorionic twin pregnancies are at increased risk of adverse outcome because of the vascular anastomoses that connect the 2 fetal circulation systems. The shared circulation is responsible for some unique complications in monochorionic twins, such as the twin-to-twin transfusion syndrome, the twin anemia polycythemia sequence, the twin reversed arterial perfusion sequence, and monoamniotic twinning. Another consequence of the shared circulation is that the well-being of one twin critically depends on that of the other. In this review, we will describe the technique of placental injection. Further, we will discuss the role of the vascular anastomoses in each of the complications described above and provide an update on their management.
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van Mieghem T, Baud D, Devlieger R, Lewi L, Ryan G, De Catte L, Deprest J. Minimally invasive fetal therapy. Best Pract Res Clin Obstet Gynaecol 2012; 26:711-25. [DOI: 10.1016/j.bpobgyn.2012.03.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 03/21/2012] [Indexed: 12/31/2022]
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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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