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Ventura W, Sugajara R, Quintana W, Llancarí P, Novoa RH. A systematic review of early intrauterine intervention at 12 + 0 to 16 + 6 weeks in twin reversed arterial perfusion sequence. Eur J Obstet Gynecol Reprod Biol 2024; 295:92-97. [PMID: 38342009 DOI: 10.1016/j.ejogrb.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 01/08/2024] [Accepted: 02/01/2024] [Indexed: 02/13/2024]
Abstract
There is some evidence that in twin reversed arterial perfusion sequence, intervention at early gestational age could prevent a spontaneous death of the pump twin, achieving a better global survival. OBJECTIVE To review the perinatal outcomes of early intervention in pregnancies complicated by twin reversed arterial perfusion (TRAP) sequence. STUDY DESIGN A comprehensive search from inception to December 2022 was conducted on databases including MEDLINE, EMBASE, Cochrane Library and LILACS. All studies that reported intervention in twin or triplet pregnancy complicated with TRAP sequence at 12 + 0 to 16 + 6 weeks of gestation were eligible. A descriptive and bivariate analysis was performed. RESULTS Out of the 222 full-text articles, 44 studies reporting 108 cases of early intervention in TRAP sequence were included. A successful procedure was achieved in 105 (95.5 %) interventions: 89 (94.7 %) among twin pregnancies and 16(100 %) among triplet pregnancies. An overall livebirth rate was achieved in 75 patients (70.8 %): intrafetal laser group 55 (73.3 %), radiofrequency 10 (76.9 %) and endoscopic laser 3 (75.0 %). The median gestational age at delivery was 38 + 0 (37 + 4 - 39 + 4) weeks. The median treatment-delivery interval was 23 + 2 (IQR, 21 + 0-25 + 6) weeks. The most frequent adverse outcomes reported were preterm labor in 7 (13.7 %) patients. There were no severe adverse maternal outcomes. CONCLUSION Early intervention with intrafetal laser and radiofrequency in TRAP sequence achieves a livebirth rate of the pump twin of about 75 %.
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Affiliation(s)
- Walter Ventura
- Fetal Medicine Unit, Department of Obstetrics and Perinatology, Instituto Nacional Materno Perinatal, Lima, Peru; Medicina Fetal Peru & Fetal Medicine Unit at Clínica Internacional and Clinica Anglo Americana, Lima, Peru.
| | - Ricardo Sugajara
- Fetal Medicine Unit, Department of Obstetrics and Perinatology, Instituto Nacional Materno Perinatal, Lima, Peru
| | - Willy Quintana
- High-Risk Pregnancy Unit, Department of Obstetrics and Perinatology, Instituto Nacional Materno Perinatal, Lima, Peru
| | - Pedro Llancarí
- Emergency Department, Instituto Nacional Materno Perinatal, Lima, Peru
| | - Rommy H Novoa
- High-Risk Pregnancy Unit, Department of Obstetrics and Perinatology, Instituto Nacional Materno Perinatal, Lima, Peru
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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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Chaveeva P, Poon LC, Sotiriadis A, Kosinski P, Nicolaides KH. Optimal Method and Timing of Intrauterine Intervention in Twin Reversed Arterial Perfusion Sequence: Case Study and Meta-Analysis. Fetal Diagn Ther 2014; 35:267-79. [DOI: 10.1159/000358593] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 12/30/2013] [Indexed: 11/19/2022]
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Beck V, Lewi P, Gucciardo L, Devlieger R. Preterm Prelabor Rupture of Membranes and Fetal Survival after Minimally Invasive Fetal Surgery: A Systematic Review of the Literature. Fetal Diagn Ther 2012; 31:1-9. [DOI: 10.1159/000331165] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Accepted: 07/26/2011] [Indexed: 11/19/2022]
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Sepulveda W, Wong AE, Bustos JC, Flores X, Alcalde JL. Acardiac fetus complicating a triplet pregnancy: management and outcome. Prenat Diagn 2009; 29:794-9. [DOI: 10.1002/pd.2291] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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O'Donoghue K, Barigye O, Pasquini L, Chappell L, Wimalasundera RC, Fisk NM. Interstitial laser therapy for fetal reduction in monochorionic multiple pregnancy: loss rate and association with aplasia cutis congenita. Prenat Diagn 2008; 28:535-43. [PMID: 18509857 DOI: 10.1002/pd.2025] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To evaluate experience with interstitial laser therapy for intrafetal vascular ablation in monochorionic (MC) multiple pregnancy. METHODS MC pregnancies that underwent fetal reduction between 1998 and 2007 by interstitial laser therapy were reviewed. Indications were twin reversed arterial perfusion sequence (TRAP) (n = 10), twin-to-twin transfusion (6), discordant abnormality (7) or growth (1) and high-order multiples (6). RESULTS Thirty pregnancies treated at 15 weeks (median, range: 11 weeks-20 weeks, 5 days) had no technical failures but four manifested procedure-related amniorrhexis. Four of 38 remaining fetuses suffered intrauterine death (IUFD) within 24 h, giving an early procedure-related fetal loss rate of 10% per pregnancy and 11% per fetus. A further five IUFDs occurred within 2 weeks, giving a maximum procedure-related loss rate of 27% per pregnancy and 24% per fetus. Median gestation at delivery was 37 weeks (18 weeks, 1 day-41 weeks, 3 days) for pregnancies continuing > 2 weeks. Perinatal survival was 26 of 38 (68%) in nonreduced fetuses. Two of 26 neonates (8%) were diagnosed with aplasia cutis congenita (ACC). CONCLUSION Interstitial laser therapy in complicated MC pregnancies carries significant risks of unintended fetal loss and may be associated with ACC.
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Affiliation(s)
- Keelin O'Donoghue
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Institute of Reproductive and Developmental Biology, Imperial College London, Hammersmith Campus, London W12 0HS, UK.
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7
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Abstract
Monochorionic twins have placental anastomoses that to varying degrees create a common circulation. This presents unique challenges for the performance of selective fetal termination in cases of twin-twin transfusion syndrome, twin reversed arterial perfusion sequence, or discordant twin abnormalities. Multiple methods of interrupting the affected twin's circulation have been attempted with variable success. One of the most frequent complications of any approach is iatrogenic preterm premature rupture of membranes. Laser coagulation in the midtrimester appears to be safe and effective; however, it is only available at limited centers. Currently, bipolar coagulation is the method of choice in the second half of pregnancy. The recently reported technique of radiofrequency ablation appears to be successful with minimal complications. Exploration of further percutaneous and noninvasive techniques, as well as interventions to decrease the morbidity arising from preterm membrane rupture, may lead to increased survival of the remaining twin and reduced risk of maternal complications.
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Affiliation(s)
- Alexandra C Spadola
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY 10032, USA
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Chen CP. Acardiac Twinning (Twin Reversed Arterial Perfusion Sequence): A Review of Prenatal Management. Taiwan J Obstet Gynecol 2005. [DOI: 10.1016/s1028-4559(09)60121-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Wong AE, Sepulveda W. Acardiac anomaly: current issues in prenatal assessment and treatment. Prenat Diagn 2005; 25:796-806. [PMID: 16170844 DOI: 10.1002/pd.1269] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Acardiac anomaly is a rare condition affecting monochorionic multiple pregnancies. We review this condition with emphasis on its prenatal diagnostic features and treatment options. Due to the parasitic hemodynamic dependence of the acardiac twin on the pump twin, it is important to monitor the pump twin for signs of decompensation and, if indicated, intervene by interrupting vascular supply to the acardiac twin. The goal of treatment is to maximize the pump-twin's chance of survival. To assist with the decision of when to treat, we suggest a new classification system based on prognostic factors, specifically the size and growth of the acardiac twin and the cardiovascular condition of the pump twin. When the acardiac twin is small and no signs of cardiovascular impairment in the pump twin are present, we suggest serial ultrasound surveillance to detect any worsening of the condition. In cases with a large acardiac twin or rapid growth of the acardiac mass, we recommend prompt intervention. Once treatment is indicated, the intrafetal approach to interrupt the vascular supply to the acardiac twin appears to be superior to cord occlusion techniques as it is simpler, safer and more effective. The first line of treatment, if available, should be ultrasound-guided laser coagulation or radiofrequency ablation of the intrafetal vessels.
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Affiliation(s)
- Amy E Wong
- Fetal Medicine Center, Department of Obstetrics and Gynecology, Clinica Las Condes, Santiago, Chile
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Sepulveda W, Corral E, Aiello H, Otaño L, Paredes R, Escobar MF, Heredia F, Quiroz V. Intrafetal Alcohol Chemosclerosis of Acardiac Twins: A Multicenter Experience. Fetal Diagn Ther 2004; 19:448-52. [PMID: 15305102 DOI: 10.1159/000078998] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2003] [Accepted: 09/11/2003] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To report a multicenter experience with intrafetal alcohol chemosclerosis in the treatment of pregnancies complicated with the twin reversed arterial perfusion sequence. METHODS Percutaneous injection of 1- 2 ml of absolute alcohol into the intra-abdominal segment of the single umbilical artery was performed in 8 acardiac twins. Cases were collected from 5 centers following a standardized protocol. The procedure was performed under continuous ultrasound control, using color Doppler ultrasound to identify the main arterial vessel entering the abdomen of the acardiac twin and passing a 20-gauge spinal needle into the targeted vessel. Intraoperative and short-term complications were noted. Information on pregnancy outcome was obtained by reviewing the medical records or contacting the referring obstetrician. RESULT At the time of the procedure, the acardiac twin was severely hydropic and the size exceeded 70% of the size of the pump twin in all cases. In addition, there were associated complications in all the pump twins including polyhydramnios in 8 cases (100%), cardiac insufficiency in 5 (63%), and fetal growth restriction in 1 (13%). The procedure was performed at a mean gestational age of 24.7 weeks (range 20-32), and it was technically successful in all cases. However, it was complicated with thrombosis of the umbilical vessels of the pump twin in 1 case, and transient bradycardia in 2 others. These 3 pump twins died in utero as a result of the procedure. The other 5 procedures were technically and clinically successful, resulting in an overall survival rate of 63%. In 4 pregnancies, the pump twin was delivered after 35 weeks and had no neonatal complications. CONCLUSIONS Intrafetal alcohol chemosclerosis is a simple procedure that can be performed in any fetal medicine center around the world to stop the vascular supply to acardiac twins. However, the main concern with this technique is intravascular transfer of the ablative material to the circulation of the pump twin. The use of this technique should therefore be restricted to those pregnancies with poor prognostic factors and in countries where more sophisticated methods for the treatment of this condition are not available.
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Pasquini L, Wimalasundera RC, Fisk NM. Management of other complications specific to monochorionic twin pregnancies. Best Pract Res Clin Obstet Gynaecol 2004; 18:577-99. [PMID: 15279818 DOI: 10.1016/j.bpobgyn.2004.04.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Monochorionic (MC) twins have a 3-10-fold higher perinatal mortality and morbidity than dichorionic twins. This is largely attributable to their common vascular architecture and the high rate of discordant fetal growth, growth restriction and congenital abnormalities. In the event of a single intrauterine death (IUD), intertwin agonal transfusion results in up to a 38% risk of death and a 46% risk of neurological injury to the co-twin. This chapter addresses the management of complications unique to MC twins. The primary aim of management is to prevent single IUD or, if inevitable, prevent agonal transfusion occurring by vascular occlusive selective feticide. Older fetoscopic techniques have been replaced by the simpler ultrasound-guided techniques of interstitial laser and bipolar cord occlusion. Their application in twin reversed-arterial perfusion sequence has been associated with a 50% reduction of perinatal mortality in the pump twin. Moreover, prophylactic interstitial laser therapy in early pregnancy might obviate the technical and clinical difficulties in the presence of fetal decompensation in later pregnancy. Recent strategies to reduce the high perinatal mortality due to cord entanglement in antenatally diagnosed monoamniotic twins including medical amnioreduction and elective caesarean delivery at 32 weeks, are also discussed.
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Affiliation(s)
- L Pasquini
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Du Cane Road, Hammaersmith, W12 0HS London, UK.
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Abstract
Fetal surgery is now an accepted modality for treatment of a variety of lethal and non-lethal congenital conditions. It represents a new, fast-moving frontier of medicine in which cooperative mulitdisciplinary effort and input are required to assure both fetal and maternal welfare. A wide range of therapeutic strategies from percutaneous to open invasive techniques has led to a complex list of different procedures for different diseases. This review identifies the most common disease entities managed by fetal intervention, examines the evolution in development of techniques to those currently used, and describes the prospective, randomized trials presently underway that are designed to establish the safety and determine true efficacy of treatment. Fetal surgery as a (multi)discipline continues to strive to minimize maternal and fetal risk. Undoubtedly, as tocolytic therapy and neonatal intensive efforts improve, fetal therapy will expand.
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Affiliation(s)
- Raul A Cortes
- Division of Pediatric Surgery, The Fetal Treatment Center, University of California, San Frncisrco, CA 94143-0570, USA
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Ville Y. Selective feticide in monochorionic pregnancies: toys for the boys or standard of care? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2003; 22:448-450. [PMID: 14618655 DOI: 10.1002/uog.931] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Affiliation(s)
- Y Ville
- Universite Paris Ouest, Service de Gynecologie Obstetrique, CHI Poissy-St Germain, 78303 Poissy Cedex 03, France.
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Tan TYT, Sepulveda W. Acardiac twin: a systematic review of minimally invasive treatment modalities. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2003; 22:409-419. [PMID: 14528480 DOI: 10.1002/uog.224] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
This review of the literature aimed to determine pregnancy outcomes after minimally invasive treatment for occluding vascular supply to acardiac twins. A MEDLINE search was performed until 2002 using the terms 'acardiac', 'acardius', 'twin reversed arterial perfusion (TRAP) sequence' and 'chorangiopagus parasiticus' and 207 articles published in the English-language literature were identified. These articles and the corresponding cited references in English were reviewed. We identified 32 reports involving 74 cases of acardiac twin treated by minimally invasive techniques. Seventy one cases were included for analysis including 40 treated by cord occlusion and 31 by intrafetal ablation. Cord occlusion was first attempted by embolization (n = 5), cord ligation (n = 15), laser coagulation (n = 10), bipolar diathermy (n = 7) and monopolar diathermy (n = 3). Intrafetal ablation was performed by alcohol (n = 5), monopolar diathermy (n = 9), interstitial laser (n = 4) and radiofrequency (n = 13). The overall median gestational ages at treatment and delivery were 21 (range, 14-28) weeks and 36 (range, 19-42) weeks, respectively, with a median treatment-delivery interval of 13 (range, 0-25) weeks. The overall pump twin survival rate was 76% (n = 54). Intrafetal ablation was associated with later median gestational age at delivery (37 vs. 32 weeks, P = 0.04) and higher median treatment-delivery interval (16 vs. 9.5 weeks, P = 0.02) compared with cord occlusion techniques. It was also associated with a lower technical failure rate (13% vs. 35%, P = 0.03), lower rate of premature delivery or rupture of membranes before 32 weeks (23% vs. 58%, P = 0.003) and higher rate of clinical success (77% vs. 50%, P = 0.02) than cord occlusion techniques. There were no statistically significant differences in terms of outcome between the subgroups of fetoscopic- or ultrasound-guided cord occlusion techniques. This review suggests that intrafetal ablation is the treatment of choice for acardiac twins because it is simpler, safer and more effective when compared with the cord occlusion techniques.
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Affiliation(s)
- T Y T Tan
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Institute of Reproductive and Developmental Biology, Imperial College London, Hammersmith Campus, London, UK
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Current awareness in prenatal diagnosis. Prenat Diagn 2003; 23:522-8. [PMID: 12858868 DOI: 10.1002/pd.530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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