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Yang Y, Ye X, Sun X. Clinical outcomes of fetal selective reduction in dichorionic triplet pregnancies. J Chin Med Assoc 2024; 87:103-108. [PMID: 37962135 DOI: 10.1097/jcma.0000000000001017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND It is recommended to reduce triplet pregnancy containing monochorionic (MC) twins to singleton. Given that some couples with infertility are eager to retain twins, better strategy is needed to avoid obstetrical risks and satisfy their strong wish. This retrospective observational study aimed to investigate the outcomes of triplet pregnancy reduction. METHODS Subjects with triplet pregnancies who underwent selective reduction between 2016 and 2019 at our hospital were enrolled. A total of 66 subjects with dichorionic triplet (DCT) with MC twins and an MC singleton were divided into two groups: group A (N = 38), reduced to dichorionic diamniotic (DCDA) twins; group B (N = 28), reduced to MC diamniotic (MCDA) twins. Obstetrical and perinatal outcomes were compared between groups. RESULTS Group A had significantly lower rates of early miscarriage (0% vs 14.3%, p = 0.028), cesarean section (81.6% vs 100%, p = 0.041), and late premature delivery (21.1% vs 45.4%, p = 0.047) than group B. Significantly higher rates of full-term delivery (71% vs 36.4%, p = 0.009) and take-home baby (100% vs 78.6%, p = 0.004), and higher gestational age at delivery (median: 38 [36.9, 39.0] vs 35.8 [34.4, 37.0] weeks, p < 0.001), total neonatal weight (2899.7 ± 647.6 vs 2354.4 ± 651.8 g, p < 0.001), weight of twins (2550 vs 2350 g, p = 0.039), and weight of larger neonate in twins (2790 vs 2500 g, p = 0.045) were observed in group A compared to group B. CONCLUSION DCT reduced to DCDA twins confers better pregnancy outcomes than into MCDA twins. This might benefit for triplet pregnancy subjects who strongly want to retain fraternal twins.
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Affiliation(s)
- Yuezhou Yang
- Shanghai Jiai Genetics and In Vitro Fertilization Center, Obstetrics and Gynecology Hospital affiliated to Fudan University, Shanghai, China
| | - Xuping Ye
- Department of Obstetrics, Obstetrics and Gynecology Hospital affiliated to Fudan University, Shanghai, China
| | - Xiaoxi Sun
- Keyes Laboratory of Female Reproductive Endocrine Related Diseases, Obstetrics and Gynecology Hospital affiliated to Fudan University, Shanghai, China
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2
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Moradi B, Badraqe N, Rahimi Sharbaf F, Firouznia K, Shirazi M, Kazemi MA, Rahimi R. Early detection of ischemic brain injuries by diffusion-weighted imaging after radiofrequency ablation for fetal reduction in monochorionic pregnancies. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:1288-1296. [PMID: 35635295 DOI: 10.1002/jcu.23237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 03/22/2022] [Accepted: 03/26/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND This study aimed to investigate the additional advantages of magnetic resonance imaging (MRI), particularly diffusion-weighted imaging (DWI) over fetal ultrasound in the detection of acute ischemic cerebral injuries in complicated monochorionic (MC) pregnancies that underwent selective reduction by radiofrequency ablation (RFA). METHODS This prospective cohort study was conducted on 40 women with complicated MC pregnancies who were treated by RFA. Fetal brain imaging by DWI and conventional MRI was performed either in the early (within 10 days after RFA) or late phase (after 3-6 weeks) in the surviving fetuses to detect both acute and chronic ischemic injuries. The presence of anemia after RFA was also evaluated by Doppler ultrasound. RESULTS Overall, 13 of the total 43 fetuses (30.23%) demonstrated MRI abnormalities with normal brain ultrasound results including germinal matrix hemorrhage (GMH), extensive cerebral ischemia, and mild ventriculomegaly. Although seven fetuses with GMH eventually survived, fetuses that demonstrated ischemic lesions and ventriculomegaly on MRI died in the uterus. CONCLUSION The absence of abnormal cerebral lesions or anemia on ultrasound and Doppler exams does not necessarily rule out fetal brain ischemia. Performing early MRI, particularly DWI seems to be a reasonable option for detection of early intracranial ischemic changes and better management of complicated multiple pregnancies which were treated by RFA.
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Affiliation(s)
- Behnaz Moradi
- Department of Radiology, Yas Complex Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Department of radiology, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Medical Imaging Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Narges Badraqe
- Department of radiology, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Medical Imaging Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Rahimi Sharbaf
- Maternal, Fetal and Neonatal Research Center, Yas Complex Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Kavous Firouznia
- Department of radiology, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Medical Imaging Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahboobeh Shirazi
- Maternal, Fetal and Neonatal Research Center, Yas Complex Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Kazemi
- Department of radiology, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Medical Imaging Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
- Department of Radiology, Amiralam Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Rahil Rahimi
- Department of radiology, Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Medical Imaging Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
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3
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Application and Influencing Factors of Radiofrequency Ablation in Monochorionic Pregnancy. MATERNAL-FETAL MEDICINE 2022. [DOI: 10.1097/fm9.0000000000000163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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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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Li N, Sun J, Wang J, Jian W, Lu J, Miao Y, Li Y, Chen F, Chen D, Ye X, Chen M. Selective termination of the fetus in multiple pregnancies using ultrasound-guided radiofrequency ablation. BMC Pregnancy Childbirth 2021; 21:821. [PMID: 34893028 PMCID: PMC8662893 DOI: 10.1186/s12884-021-04285-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 11/23/2021] [Indexed: 12/02/2022] Open
Abstract
Background To evaluate the perinatal outcomes in women with selective termination using ultrasound-guided radiofrequency ablation (RFA). Methods Complicated monochorionic (MC) twin pregnancies and multiple pregnancies with an indication for selective termination by ultrasound-guided coagulation of the umbilical cord with RFA under local anesthesia between July 2013 and Jan 2020 were reviewed. We analyzed the indications, gestational age at the time of the procedure, cycles of RFA, duration of the procedure, and perinatal outcome. Results Three hundred and thirteen patients were treated during this period. Seven of whom were lost of follow-up. The remaining 306 cases, including 266 pairs of monochorionic diamniotic (MCDA) twins (86.93%), two pairs of monoamniotic twins (0.65%), 30 dichorionic triamniotic (DCTA) triplets (1%), and three monochorionic triamniotic (MCTA) triplets (0.98%), were analyzed. Indications included twin-to-twin transfusion syndrome (TTTS) (n = 91), selective fetal growth restriction (sFGR) (n = 83), severe discordant structural malformation (n = 78), multifetal pregnancy reduction (MFPR) (n = 78), twin reverse arterial perfusion sequence (TRAPS) (n = 19), and twin anemia-polycythemia sequence (TAPS) (n = 3). Upon comparison of RFA performed before and after 20 weeks, the co-twin loss rate (20.9% vs. 21.5%), the incidence of preterm premature rupture of membranes (PPROM) within 24 h (1.5% vs. 1.2%), and the median gestational age at delivery [35.93 (28–38) weeks vs. 36 (28.54–38.14) weeks] were similar (p > 0.05). Conclusions RFA is a reasonable option when indicated in multiple pregnancies and complicated monochorionic pregnancies. In our experience, the overall survival rate was 78.76% with RFA in selective feticide, and early treatment increases the likelihood of survival for the remaining fetus because the fetal loss rate is similar before and after 20 weeks.
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Affiliation(s)
- Nan Li
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Jimei Sun
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Jiayan Wang
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Wei Jian
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Jing Lu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Yonghui Miao
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Yufan Li
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Fei Chen
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Dunjin Chen
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China
| | - Xiaoqing Ye
- Department of Ultrasound, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Min Chen
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Liwan District, Guangzhou, China.
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Wu T, Chen Z, Yin X, Shi H, Niu J, Xie J, Wei Y, Wang X. Perinatal outcomes after selective feticide via umbilical cord occlusion in complicated monochorionic pregnancies: A systematic review and meta-analysis. Prenat Diagn 2021; 42:37-48. [PMID: 34699084 DOI: 10.1002/pd.6064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 07/14/2021] [Accepted: 10/19/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE We aimed to compare perinatal outcomes between umbilical cord occlusion techniques in monochorionic pregnancies, including umbilical cord ligation, fetoscopic laser coagulation, interstitial laser coagulation, bipolar cord occlusion, radiofrequency ablation, and microwave ablation. METHODS This study was registered with PROSPERO (CRD42020158861). PubMed, Web of Science, Cochrane Library, and Embase were searched for studies published up to May 2020. The DerSimonian-Laird random-effects model was used for the meta-analysis. Subgroup analyses were performed to compare the outcomes among the six techniques. Meta-regression was used to adjust for confounders. RESULTS Thirty-four studies with 1646 participants were included. The overall survival was 76.5% after umbilical cord ligation, 78.8% after fetoscopic laser coagulation, 60.3% after interstitial laser coagulation, 79.2% after bipolar cord occlusion, 77.5% after radiofrequency ablation, and 75.0% after microwave ablation. Subgroup comparison showed the rates of overall survival and preterm premature rupture of membranes were not significant different among six techniques. However, rates of fetal loss, premature birth, live birth, and neonatal death differed significantly among the six groups. CONCLUSIONS The choice of umbilical cord occlusion techniques will affect perinatal outcomes. We suggested that the choice of umbilical cord occlusion techniques should fully consider these differences among techniques.
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Affiliation(s)
- Tianchen Wu
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - Ziyi Chen
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Xiaohan Yin
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - Huifeng Shi
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Jieqiong Niu
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - Jialei Xie
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - Yuan Wei
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Xiaoli Wang
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China.,Key Laboratory of Reproductive Health, National Health Commission, Beijing, China
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7
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Rao MG, Vieira L, Kaplowitz E, Overbey JR, Johnson S, Paul K, Lookstein R, Rebarber A, Fox NS, Stone J. Elective fetal reduction by radiofrequency ablation in monochorionic diamniotic twins decreases adverse outcomes compared to ongoing monochorionic diamniotic twins. Am J Obstet Gynecol MFM 2021; 3:100447. [PMID: 34314851 DOI: 10.1016/j.ajogmf.2021.100447] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 07/08/2021] [Accepted: 07/20/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Multifetal pregnancy reduction is a technique used to reduce the fetal number to mitigate the risks of adverse outcomes associated with multiple gestations. Monochorionic diamniotic twin pregnancies are subject to unique complications, contributing to adverse pregnancy outcomes. Thus, patients have an option to electively reduce 1 fetus to improve outcomes. OBJECTIVE This study aimed to compare outcomes of elective reduction of monochorionic diamniotic twins by radiofrequency ablation to planned ongoing monochorionic diamniotic twins. STUDY DESIGN We performed a retrospective review of 315 monochorionic diamniotic twin gestations that underwent first-trimester ultrasound within 1 institution. Planned electively reduced twins were compared with ongoing monochorionic diamniotic twins. All reductions were performed via radiofrequency ablation of the cord insertion site into the fetal abdomen. The primary outcome was preterm birth at <36 weeks' gestation. Secondary outcomes included gestational age at delivery; preterm birth at less than 37-, 34-, 32-, and 28-weeks' gestation; unintended loss; and adverse perinatal outcomes. RESULTS Among 315 monochorionic diamniotic pregnancies, 14 (4.4%) underwent elective multifetal pregnancy reduction, and 301 (95.6%) were planned ongoing twins. The mean gestational age of radiofrequency ablation in the elective multifetal pregnancy reduction group was 15.1±0.68 weeks. Patients who underwent elective multifetal pregnancy reduction had significantly higher maternal age (P<.01) and were more likely to be Asian (P<.01). Moreover, they were more likely to have undergone in vitro fertilization (P=.03) and chorionic villus sampling (P<.01). There was a significantly higher rate of term deliveries in the elective radiofrequency ablation group compared with ongoing twins (gestational age, 38 weeks [interquartile range, 36.1-39.1] vs 35.9 weeks [interquartile range, 34.0-36.9]; P<.01). Patients with ongoing pregnancies had a trend of increased rate of preterm birth at <36 weeks' gestation (odds ratio, 3.4; 95% confidence interval, 1.0-12.0; P=.06), a significantly increased risk of preterm birth at <37 weeks' gestation (odds ratio, 8.0; 95% confidence interval, 2.4-26.4; P<.01), and no difference at less than 34-, 32-, or 28- weeks' gestation. All patients who underwent elective radiofrequency ablation had successful pregnancies with no pregnancy losses or terminations. Of ongoing gestations, 36 required procedures, including 16 (5.3%) medically indicated radiofrequency ablation, 14 (4.6%) laser ablation, and 6 (1.9%) amnioreductions. Furthermore, 22 patients (7.3%) with planned ongoing twins had total pregnancy loss at <24 weeks' gestation. Notably, 12 patients (4.0%) had unintended loss of 1 fetus before 24 weeks' gestation in the ongoing pregnancy cohort, and 12 patients (4.0%) had unintended loss of both fetuses before 24 weeks' gestation. Moreover, 5 patients (1.7%) in the ongoing pregnancy group had intrauterine fetal demise at >24 weeks' gestation and 10 patients (3.3%) electively terminated both fetuses. There was no significant difference in loss rates between the 2 groups. CONCLUSION In this study of monochorionic diamniotic twins, patients who elected to undergo multifetal pregnancy reduction had significantly lower rates of preterm birth at <37 weeks and a lower trend of preterm birth at <36 weeks' gestation without an increased risk of pregnancy loss. Median gestational age at delivery was significantly higher in the elective multifetal pregnancy reduction group (38 weeks) than in the ongoing pregnancy group (35.9 weeks). Further research is needed to clarify if multifetal pregnancy reduction improves long-term outcomes.
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Affiliation(s)
- Manasa G Rao
- Departments of Obstetrics, Gynecology, and Reproductive Science (Ms Rao, Drs Vieira and Johnson, Ms Paul, and Drs Lookstein, Rebarber, Fox, and Stone).
| | - Luciana Vieira
- Departments of Obstetrics, Gynecology, and Reproductive Science (Ms Rao, Drs Vieira and Johnson, Ms Paul, and Drs Lookstein, Rebarber, Fox, and Stone)
| | - Elianna Kaplowitz
- Population Health Science and Policy (Ms Kaplowitz and Dr Overbey), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jessica R Overbey
- Population Health Science and Policy (Ms Kaplowitz and Dr Overbey), Icahn School of Medicine at Mount Sinai, New York, NY
| | - Shaelyn Johnson
- Departments of Obstetrics, Gynecology, and Reproductive Science (Ms Rao, Drs Vieira and Johnson, Ms Paul, and Drs Lookstein, Rebarber, Fox, and Stone)
| | - Keisha Paul
- Departments of Obstetrics, Gynecology, and Reproductive Science (Ms Rao, Drs Vieira and Johnson, Ms Paul, and Drs Lookstein, Rebarber, Fox, and Stone)
| | - Robert Lookstein
- Departments of Obstetrics, Gynecology, and Reproductive Science (Ms Rao, Drs Vieira and Johnson, Ms Paul, and Drs Lookstein, Rebarber, Fox, and Stone)
| | - Andrei Rebarber
- Departments of Obstetrics, Gynecology, and Reproductive Science (Ms Rao, Drs Vieira and Johnson, Ms Paul, and Drs Lookstein, Rebarber, Fox, and Stone)
| | - Nathan S Fox
- Departments of Obstetrics, Gynecology, and Reproductive Science (Ms Rao, Drs Vieira and Johnson, Ms Paul, and Drs Lookstein, Rebarber, Fox, and Stone)
| | - Joanne Stone
- Departments of Obstetrics, Gynecology, and Reproductive Science (Ms Rao, Drs Vieira and Johnson, Ms Paul, and Drs Lookstein, Rebarber, Fox, and Stone)
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Dadhwal V, Sharma KA, Rana A, Sharma A, Singh L. Perinatal outcome in monochorionic twin pregnancies after selective fetal reduction using radiofrequency ablation. Int J Gynaecol Obstet 2021; 157:340-346. [PMID: 34118068 DOI: 10.1002/ijgo.13785] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 05/23/2021] [Accepted: 06/11/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To study the perinatal outcomes in women with complicated monochorionic twin pregnancies undergoing selective fetal reduction using radiofrequency ablation (RFA). METHODS This retrospective study included 44 patients with monochorionic twin pregnancies, between 14 and 28 weeks of pregnancy, who underwent RFA for selective fetal reduction. Perinatal and maternal outcomes and procedure-related complications were analyzed. RESULTS The procedure was technically successful in all 44 cases. Indications for selective fetal reduction included twin-to-twin transfusion syndrome (52.3%), twin reversed arterial perfusion (20.5%), twins discordant for anomaly (15.9%), and selective fetal growth restriction (11.4%). Median gestational age at procedure was 222/7 weeks (range 14-266/7 ). Live birth rate was 77.3% with three neonatal deaths; so overall survival was 70.5%. Median procedure-to-delivery interval was 123/7 weeks (range 24/7 -23). There were eight losses before 24 weeks of pregnancy, which included two co-twin deaths. Median gestational age at delivery was 35 weeks (interquartile range 321/7 -37 weeks). The preterm delivery rate was 66.7% (24/36) and preterm prelabor rupture of membranes (PPROM) occurred in 22.7% (10/44) of patients. CONCLUSION Selective fetal reduction using RFA is safe and effective in complicated monochorionic pregnancies. However, the rates of PPROM and preterm delivery remain high.
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Affiliation(s)
- Vatsla Dadhwal
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India
| | - K Aparna Sharma
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India
| | - Anubhuti Rana
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India
| | - Akash Sharma
- Division of Neonatology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Lakhwinder Singh
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India
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Liu Q, Shi X, Fang L, Rao T, Shi L, Wu J. A cohort study of the perinatal outcome of radiofrequency ablation in complicated monochorionic multiple pregnancies based on a different needle insert angle. J Int Med Res 2021; 49:3000605211018432. [PMID: 34038209 PMCID: PMC8161873 DOI: 10.1177/03000605211018432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/26/2021] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To compare the pregnancy outcomes of radiofrequency ablation (RFA) for complicated multiple pregnancies between fetal abdominal and dorsal needle insertion angles. METHODS We performed a historical cohort study of patients who underwent selective reduction using RFA through different needle insertion angles from 2015 to 2018 at a local hospital. Dorsal needle insertion cases were consecutively selected and abdominal needle insertion cases were selectively enrolled. The Cox proportional hazards model was constructed to identify predictors of fetal survival time with different needle insertion angles. RESULTS The RFA procedure was performed in 28 women through an abdominal insertion angle and in 28 women through a dorsal insertion angle. There were no significant differences in perinatal outcomes between the two groups. The overall live birth rate after RFA in the two groups was 73.5% and the mean gestation was 31.6 ± 6.5 weeks. The Cox model showed that gestational age at RFA was a predictor of the duration of the period between RFA and delivery. CONCLUSION RFA conducted through the dorsal insertion angle is technically feasible for selective reduction in complex monochorionic multiple pregnancies. Gestational age at this procedure is an independent risk factor for the duration of pregnancy post-RFA.
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Affiliation(s)
- Qian Liu
- Department of Medical Genetics Centre, Guangdong Women’s and Children’s Hospital, Guangzhou City, China
| | - Xiaomei Shi
- Department of Medical Genetics Centre, Guangdong Women’s and Children’s Hospital, Guangzhou City, China
| | - Liyuan Fang
- Department of Medical Genetics Centre, Guangdong Women’s and Children’s Hospital, Guangzhou City, China
| | - Tengzi Rao
- Department of Medical Genetics Centre, Guangdong Women’s and Children’s Hospital, Guangzhou City, China
| | - Lishuang Shi
- Department of Medical Genetics Centre, Guangdong Women’s and Children’s Hospital, Guangzhou City, China
| | - Jing Wu
- Department of Medical Genetics Centre, Guangdong Women’s and Children’s Hospital, Guangzhou City, China
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Forde B, Habli M. Unique Considerations: Preterm Prelabor Rupture of Membranes in the Setting of Fetal Surgery and Higher Order Pregnancies. Obstet Gynecol Clin North Am 2021; 47:653-669. [PMID: 33121651 DOI: 10.1016/j.ogc.2020.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Two unique aspects of antenatal care occur in the setting of fetal surgery and multiple gestations. As fetal interventions increase, so do the number of cases of iatrogenic preterm prelabor rupture of membranes (PPROM). Because of the amniotic sac's inability to heal, the risk of PPROM after surgery is directly correlated with the number of interventions, the size of the defect, and the surgery performed. Higher order gestations also carry an increased risk of PPROM. This paper reviews the risks and management of PPROM in the setting of the various prenatal interventions as well as in the setting of multiple gestations.
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Affiliation(s)
- Braxton Forde
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Medical Sciences Building, Room 4555, 231 Albert Sabin Way, Cincinnati, OH 45267-0526, USA.
| | - Mounira Habli
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Good Samaritan Hospital, Cincinnati, OH, USA; Fetal Care Center of Cincinnati, Cincinnati Children's Hospital, Cincinnati, OH, USA
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Shanahan MA, Bebbington MW. Placental Anatomy and Function in Twin Gestations. Obstet Gynecol Clin North Am 2020; 47:99-116. [PMID: 32008674 DOI: 10.1016/j.ogc.2019.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
With an increasing incidence of twin gestations, understanding the inherent risks associated with these pregnancies is essential in modern obstetrics. The unique differences in placentation in twins contribute to the increased risks. Monochorionic twins are susceptible to complications because of their unique placental architecture, including twin-to-twin transfusion syndrome, the twin anemia-polycythemia sequence, selective intrauterine growth restriction, and the twin reversed arterial perfusion sequence. Knowing the clinical correlations of placental anatomy in these gestations helps perinatal pathologists perform a more informed placental evaluation, allowing for better care for the mother and her children.
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Affiliation(s)
- Matthew A Shanahan
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Washington University in St. Louis School of Medicine, 660 South Euclid Avenue, Mailstop 8064-37-1005, St. Louis, MO 63110, USA
| | - Michael W Bebbington
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Washington University in St. Louis School of Medicine, 660 South Euclid Avenue, Mailstop 8064-37-1005, St. Louis, MO 63110, USA.
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12
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Colmant C, Lapillonne A, Stirnemann J, Belaroussi I, Leroy-Terquem E, Kermovant-Duchemin E, Bussieres L, Ville Y. Impact of different prenatal management strategies in short- and long-term outcomes in monochorionic twin pregnancies with selective intrauterine growth restriction and abnormal flow velocity waveforms in the umbilical artery Doppler: a retrospective observational study of 108 cases. BJOG 2020; 128:401-409. [PMID: 32416618 DOI: 10.1111/1471-0528.16318] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To review perinatal and neurodevelopmental outcome (NDO) following selective fetoscopic laser coagulation (SFLC), cord coagulation (CC) or expectant management of monochorionic diamniotic twin pregnancies complicated with selective intrauterine growth restriction (sIUGR) and absent or reverse end-diastolic flow (AREDF) in the umbilical arteries (UA). DESIGN AND SETTING Single-centre retrospective observational study. POPULATION 108 cases of sIUGR diagnosed before 26+6 weeks' gestation with AREDF in the UA. METHODS Survival rate and potential risk factors were analysed. NDO was assessed using parental questionnaires. MAIN OUTCOMES MEASURES Survival, gestational age at delivery and NDO. RESULTS SFLC, CC and EM were performed in 13, 50 and 45 cases, respectively, with an overall survival of 23.1, 40 and 77.8% and intrauterine demise of the co-twin of 30.8, 10 and 6.7% respectively. Intrauterine demise of the sIUGR twin occurred in 76.9 and 17.8% following SFLC and EM, respectively. The discordance in EFW at diagnosis was higher and absent/negative a-wave in the ductus venosus (DV) was more prevalent in the surgical groups. NDO in survivors at follow up was abnormal in 0 and 18% in the smaller twin following SFLC and EM, respectively, and in 25, 24 and 21% in the larger twin following SFLC, CC and EM, respectively. CONCLUSION SFLC yielded a poor result. EM seems a valid option when EFW discordance is <30% and a-wave in DV is positive. Otherwise, CC should be considered to protect the AGA co-twin. The long-term outcome of both small and large twins seems unaffected by the choice in primary prenatal management strategy. TWEETABLE ABSTRACT In type II sIUGR in MC twins, long-term neurodevelopment is normal in over 80% of the survivors.
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Affiliation(s)
- C Colmant
- Obstetrics and Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - A Lapillonne
- EA7328 and PACT, Université Paris Descartes, Paris, France.,Neonatology and Intensive Care Unit, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - J Stirnemann
- Obstetrics and Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France.,EA7328 and PACT, Université Paris Descartes, Paris, France
| | - I Belaroussi
- Obstetrics and Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | | | - E Kermovant-Duchemin
- EA7328 and PACT, Université Paris Descartes, Paris, France.,Neonatology and Intensive Care Unit, Hôpital Necker Enfants Malades, AP-HP, Paris, France
| | - L Bussieres
- Obstetrics and Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France.,EA7328 and PACT, Université Paris Descartes, Paris, France
| | - Y Ville
- Obstetrics and Fetal Medicine, Hôpital Necker Enfants Malades, AP-HP, Paris, France.,EA7328 and PACT, Université Paris Descartes, Paris, France
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13
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Sacco A, Van der Veeken L, Bagshaw E, Ferguson C, Van Mieghem T, David AL, Deprest J. Maternal complications following open and fetoscopic fetal surgery: A systematic review and meta-analysis. Prenat Diagn 2019; 39:251-268. [PMID: 30703262 PMCID: PMC6492015 DOI: 10.1002/pd.5421] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 01/16/2019] [Accepted: 01/20/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To establish maternal complication rates for fetoscopic or open fetal surgery. METHODS We conducted a systematic literature review for studies of fetoscopic or open fetal surgery performed since 1990, recording maternal complications during fetal surgery, the remainder of pregnancy, delivery, and after the index pregnancy. RESULTS One hundred sixty-six studies were included, reporting outcomes for open fetal (n = 1193 patients) and fetoscopic surgery (n = 9403 patients). No maternal deaths were reported. The risk of any maternal complication in the index pregnancy was 20.9% (95%CI, 15.22-27.13) for open fetal and 6.2% (95%CI, 4.93-7.49) for fetoscopic surgery. For severe maternal complications (grades III to V Clavien-Dindo classification of surgical complications), the risk was 4.5% (95% CI 3.24-5.98) for open fetal and 1.7% (95% CI, 1.19-2.20) for fetoscopic surgery. In subsequent pregnancies, open fetal surgery increased the risk of preterm birth but not uterine dehiscence or rupture. Nearly one quarter of reviewed studies (n = 175, 23.3%) was excluded for failing to report the presence or absence of maternal complications. CONCLUSIONS Maternal complications occur in 6.2% fetoscopic and 20.9% open fetal surgeries, with serious maternal complications in 1.7% fetoscopic and 4.5% open procedures. Reporting of maternal complications is variable. To properly quantify maternal risks, outcomes should be reported consistently across all fetal surgery studies.
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Affiliation(s)
- Adalina Sacco
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Lennart Van der Veeken
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
| | - Emma Bagshaw
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Catherine Ferguson
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
| | - Tim Van Mieghem
- Department of Obstetrics and GynaecologyMount Sinai Hospital and University of TorontoTorontoOntarioCanada
| | - Anna L. David
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- National Institute for Health ResearchUniversity College London Hospitals Biomedical Research CentreLondonUK
| | - Jan Deprest
- Department of Maternal and Fetal MedicineInstitute for Women's Health, University College LondonLondonUK
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical SciencesKU LeuvenLeuvenBelgium
- Clinical Department Obstetrics and GynaecologyUniversity Hospitals LeuvenLeuvenBelgium
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14
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Abdel-Sattar M, Chon AH, Llanes A, Korst LM, Ouzounian JG, Chmait RH. Comparison of umbilical cord occlusion methods: Radiofrequency ablation versus laser photocoagulation. Prenat Diagn 2018; 38:110-116. [DOI: 10.1002/pd.5196] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 12/04/2017] [Accepted: 12/10/2017] [Indexed: 01/08/2023]
Affiliation(s)
- Mira Abdel-Sattar
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine; University of Southern California; Pasadena CA USA
| | - Andrew H. Chon
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine; University of Southern California; Pasadena CA USA
| | - Arlyn Llanes
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine; University of Southern California; Pasadena CA USA
| | - Lisa M. Korst
- Childbirth Research Associates; North Hollywood CA USA
| | - Joseph G. Ouzounian
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine; University of Southern California; Pasadena CA USA
| | - Ramen H. Chmait
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine; University of Southern California; Pasadena CA USA
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15
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Radiofrequency ablation for selective reduction in complex monochorionic multiple pregnancies: A case series. Taiwan J Obstet Gynecol 2017; 56:740-744. [DOI: 10.1016/j.tjog.2017.10.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2017] [Indexed: 01/26/2023] Open
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16
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Panciatici M, Tosello B, Blanc J, Haumonté JB, D’Ercole C, Gire C. Devenir neurodéveloppemental des nouveau-nés issus de grossesses monochoriales compliquées avec interruption sélective par ablation par radiofréquence. ACTA ACUST UNITED AC 2017; 45:197-201. [DOI: 10.1016/j.gofs.2017.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 01/26/2017] [Indexed: 11/17/2022]
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17
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Abou Chaar MK, Meyers ML, Tucker BD, Galan HL, Liechty KW, Crombleholme TM, Marwan AI. Twin pregnancy complicated by esophageal atresia, duodenal atresia, gastric perforation, and hypoplastic left heart structures in one twin: a case report and review of the literature. J Med Case Rep 2017; 11:64. [PMID: 28314387 PMCID: PMC5357333 DOI: 10.1186/s13256-016-1195-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 12/28/2016] [Indexed: 12/12/2022] Open
Abstract
Background The antenatal diagnosis of a combined esophageal atresia without tracheoesophageal fistula and duodenal atresia with or without gastric perforation is a rare occurrence. These diagnoses are difficult and can be suspected on ultrasound by nonspecific findings including a small stomach and polyhydramnios. Fetal magnetic resonance imaging adds significant anatomical detail and can aid in the diagnosis of these complicated cases. Upon an extensive literature review, there are no reports documenting these combined findings in a twin pregnancy. Therefore we believe this is the first case report of an antenatal diagnosis of combined pure esophageal and duodenal atresia in a twin gestation. Case presentation We present a case of a 30-year-old G1P0 white woman at 22-week gestation with a monochorionic-diamniotic twin pregnancy discordant for esophageal atresia, duodenal atresia with gastric perforation, hypoplastic left heart structures, and significant early gestation maternal polyhydramnios. In this case, fetal magnetic resonance imaging was able to depict additional findings including area of gastric wall rupture, hiatal hernia, dilation of the distal esophagus, and area of duodenal obstruction and thus facilitated the proper diagnosis. After extensive counseling at our multidisciplinary team meeting, the parents elected to proceed with radiofrequency ablation of the anomalous twin to maximize the survival of the normal co-twin. The procedure was performed successfully with complete cessation of flow in the umbilical artery and complete cardiac standstill in the anomalous twin with no detrimental effects on the healthy co-twin. Conclusions Prenatal diagnosis of complex anomalies in twin pregnancies constitutes a multitude of ethical, religious, and cultural factors that come into play in the management of these cases. Fetal magnetic resonance imaging provides detailed valuable information that can assist in management options including possible prenatal intervention. The combination of a cystic structure with peristalsis-like movement above the diaphragm (for example, “the upper thoracic pouch sign”), polyhydramnios, and progressive distention of the stomach and duodenum should increase suspicion for a combined pure esophageal and duodenal atresia.
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Affiliation(s)
- Mohamad K Abou Chaar
- Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, University of Colorado Denver, Anschutz Medical Center, Denver, USA
| | - Mariana L Meyers
- Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, University of Colorado Denver, Anschutz Medical Center, Denver, USA.,Department of Pediatric Radiology, University of Colorado Denver, Anschutz Medical Center, Denver, USA
| | - Bethany D Tucker
- Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, University of Colorado Denver, Anschutz Medical Center, Denver, USA.,Department of Pediatrics, University of Colorado Denver, Anschutz Medical Center, Denver, USA
| | - Henry L Galan
- Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, University of Colorado Denver, Anschutz Medical Center, Denver, USA.,Department of Obstetrics and Gynecology - Maternal Fetal Medicine, University of Colorado Denver, Anschutz Medical Center, Denver, USA
| | - Kenneth W Liechty
- Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, University of Colorado Denver, Anschutz Medical Center, Denver, USA.,Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Center, Denver, USA
| | - Timothy M Crombleholme
- Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, University of Colorado Denver, Anschutz Medical Center, Denver, USA.,Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Center, Denver, USA
| | - Ahmed I Marwan
- Colorado Fetal Care Center, Colorado Institute of Maternal and Fetal Health, University of Colorado Denver, Anschutz Medical Center, Denver, USA. .,Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Center, Denver, USA. .,Surgery and Pediatrics, Colorado Fetal Care Center - Children's Hospital Colorado, 13123 East 16th Avenue, 328, Aurora, Colorado, 80045, USA.
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18
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Fischbein R, Meeker J, Saling JR, Chyatte M, Nicholas L. Identifying families' shared disease experiences through a qualitative analysis of online twin-to-twin transfusion syndrome stories. BMC Pregnancy Childbirth 2016; 16:163. [PMID: 27422614 PMCID: PMC4946129 DOI: 10.1186/s12884-016-0952-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 07/09/2016] [Indexed: 11/10/2022] Open
Abstract
Background Twin-to-twin transfusion syndrome (TTTS) affects 10–20 % of monochorionic diamniotic (MCDA) births and accounts for 50 % of fetal loss in MCDA pregnancies. This exploratory qualitative study identified shared experiences, including potential emotional and psychosocial impacts, of this serious disease. Methods Forty-five publicly accessible, online stories posted by families who experienced TTTS were analyzed using grounded theory. Results Shared TTTS experiences included a common trajectory: early pregnancy experiences, diagnostic experiences, making decisions, interventions and variable outcomes. Families vacillated between emotional highs such as joy, excitement and relief, and lows including depression, anxiety, anger and grief. Conclusions TTTS disease experience can be considered an “emotional roller coaster” exacerbated by TTTS’s unpredictable and quickly changing nature with the potential for emotional and psychosocial effects. Increased TTTS awareness and research about its corresponding impacts can ensure appropriate patient and family support at all phases of the TTTS experience.
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Affiliation(s)
- Rebecca Fischbein
- Department of Health Policy & Management, College of Public Health, Kent State University, 800 Hilltop Drive, Moulton Hall, P.O. Box 5190, Kent, OH, 44242-0001, USA.
| | - James Meeker
- Northeast Ohio Medical University, 4209 St. Rt. 44, P.O. Box 95, Rootstown, OH, 44272-0095, USA
| | - Julia R Saling
- Northeast Ohio Medical University, 4209 St. Rt. 44, P.O. Box 95, Rootstown, OH, 44272-0095, USA
| | - Michelle Chyatte
- Northeast Ohio Medical University, 4209 St. Rt. 44, P.O. Box 95, Rootstown, OH, 44272-0095, USA
| | - Lauren Nicholas
- D'Youville College, 320 Porter Avenue, Buffalo, NY, 14201, USA
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19
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Peng R, Xie HN, Lin MF, Yang JB, Zhou Y, Chen HQ, Zhu YX. Clinical Outcomes after Selective Fetal Reduction of Complicated Monochorionic Twins with Radiofrequency Ablation and Bipolar Cord Coagulation. Gynecol Obstet Invest 2016; 81:552-558. [PMID: 27035917 DOI: 10.1159/000445291] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 03/07/2016] [Indexed: 11/19/2022]
Abstract
AIMS To review pregnancy outcomes, complication rates and neonatal neural development of selective termination procedures for complicated monochorionic (MC) twins. METHODS This was a retrospective review of the pregnancies that underwent selective reduction with radiofrequency ablation (RFA) and bipolar cord coagulation (BCC) in our institution. RESULTS Forty-eight cases underwent selective reduction with BCC and the remaining 45 with RFA. Overall survival was not statistically different between the RFA and BCC groups (71.1 and 62.5%, p = 0.379). With regard to the indications, the survival rates were not significantly different for twin to twin transfusion syndrome, twin reversed arterial perfusion, discordant anomalies and selective intrauterine growth restriction. Preterm premature rupture of membrane was not statistically different between the BCC and RFA groups (47.9 and 33.3%, p = 0.153). Five foetuses presented with abnormal middle cerebral artery-peak systolic velocity in the BCC group and 4 in the RFA group (p = 0.829). In the BCC group, neurological injury was detected in 2 neonates, presenting with cerebral dysplasia on MR scanning. In the RFA group, intracranial haemorrhage Grade III was detected in one neonate with cranial ultrasound (p = 0.607). CONCLUSIONS Overall survival and complication rates following selective reduction in complicated MC twin pregnancies is similar irrespective of whether the reduction was performed using RFA or BCC. Key Message: It seems that selective reduction in MC pregnancies with RFA does not carry a significant decrease in the overall survival and complication rates than the cases with BCC. According to our data, neurodevelopmental impairment of the co-twins is relatively seldom after selective reduction.
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Affiliation(s)
- Ruan Peng
- Department of Ultrasonic Medicine, Fetal Medical Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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20
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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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21
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van de Mheen L, Everwijn S, Haak M, Manten G, Zondervan H, Knapen M, Engels M, Erwich J, Coumans A, van Vugt J, Bilardo C, van Pampus M, de Groot C, Mol B, Pajkrt E. Outcome of Multifetal Pregnancy Reduction in Women with a Dichorionic Triamniotic Triplet Pregnancy to a Singleton Pregnancy: A Retrospective Nationwide Cohort Study. Fetal Diagn Ther 2015; 40:94-9. [DOI: 10.1159/000441650] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 10/05/2015] [Indexed: 11/19/2022]
Abstract
Objective: To study the pregnancy outcomes of women with a dichorionic triamniotic triplet pregnancy that was reduced to a singleton pregnancy and to review the literature. Methods: We performed a nationwide retrospective cohort study. We compared time to delivery and perinatal mortality in dichorionic triplet pregnancies reduced to singletons with ongoing dichorionic triplet pregnancies and primary singleton pregnancies. Additionally, we reviewed the literature on the subject. Results: We studied 46 women with a reduced dichorionic triplet pregnancy and 42 women with an ongoing dichorionic triplet pregnancy. Median gestational age at delivery was 38.7 vs. 32.8 weeks, respectively (p < 0.001). Delivery <24 weeks occurred in 9 (19.6%) women with a reduced triplet pregnancy and 4 (9.5%) with an ongoing triplet pregnancy (p = 0.19). Perinatal survival rates between the reduced group and the ongoing triplet group were not significantly different. Conclusion: Multifetal pregnancy reduction in women with a dichorionic triplet pregnancy to a singleton pregnancy prolongs median gestational age at birth. No statistically significant association was found with miscarriage and perinatal survival rates.
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22
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Yinon Y, Ashwal E, Weisz B, Chayen B, Schiff E, Lipitz S. Selective reduction in complicated monochorionic twins: prediction of obstetric outcome and comparison of techniques. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:670-677. [PMID: 25867754 DOI: 10.1002/uog.14879] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 04/07/2015] [Accepted: 04/09/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To compare the outcomes of radiofrequency ablation (RFA) and bipolar cord coagulation (BPC) methods for selective feticide in complicated monochorionic (MC) twin gestations and to determine risk factors for adverse pregnancy outcome. METHODS This was a retrospective cohort study of all patients with complicated MC twin pregnancy who underwent selective reduction in a single tertiary care center between 2000 and 2014. We compared the two methods with respect to various demographic, obstetric and perinatal outcome variables. RESULTS Fifty-three selective terminations in complicated MC twin gestations were performed, 36 by RFA and 17 by BPC. Each technique resulted in a similar overall survival rate of the remaining twin (88.9% vs 76.5%, P = 0.25). Likewise, the mean procedure-to-delivery interval, the rate of spontaneous preterm delivery < 37, < 34, < 32 and < 28 weeks and the rate of preterm prelabor rupture of the membranes did not differ between the groups. However, among patients in the BPC group, there was a trend towards earlier gestational age at delivery (31.3 vs 35.0 weeks, P = 0.09) compared with in the RFA group. There was selective reduction by RFA due to selective intrauterine growth restriction (sIUGR) in 19 cases, 17 (89.5%) of which survived perinatally, with delivery at a median gestational age of 37 weeks. There were no significant differences in perinatal outcome, irrespective of whether the procedure was performed pre- or post-viability. All post-viability reductions, most of which were by RFA, resulted in perinatal survival. CONCLUSIONS Perinatal outcome of complicated MC twin gestations undergoing selective feticide seems to be similar regardless of whether termination is by BPC or RFA. Nevertheless, RFA appears to be particularly useful in MC twins complicated by sIUGR and in cases requiring selective reduction beyond the age of viability.
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Affiliation(s)
- Y Yinon
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - E Ashwal
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - B Weisz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - B Chayen
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - E Schiff
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - S Lipitz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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23
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Gaerty K, Greer RM, Kumar S. Systematic review and metaanalysis of perinatal outcomes after radiofrequency ablation and bipolar cord occlusion in monochorionic pregnancies. Am J Obstet Gynecol 2015; 213:637-43. [PMID: 25935786 DOI: 10.1016/j.ajog.2015.04.035] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 03/31/2015] [Accepted: 04/24/2015] [Indexed: 11/29/2022]
Abstract
The aim of this study was to analyze perinatal outcomes after selective reduction in monochorionic pregnancies with the use of either radiofrequency ablation (RFA) or bipolar cord occlusion (BCO). This was a systematic review and metaanalysis that included all studies with ≥5 cases that described perinatal outcomes after BCO or RFA that were identified in PubMed, Embase, Web of Science, COCHRANE, CINAHL, Academic Search Premier, Science Direct, and MEDLINE that were published between 1965 and July 2014. For count data, incidence risk ratios (IRR; 95% confidence interval [CI]) were calculated with BCO as the reference standard. The analysis included 481 cases of BCO and 320 cases of RFA from 17 studies. The mean median gestations at procedure were 21.1 ± 1.2 weeks (BCO) and 18.8 ± 2.5 weeks (RFA; P = .03). The rate of cotwin death was higher in the RFA group (14.7%) vs the BCO group (10.6%; IRR, 1.38; 95% CI, 0.93-2.05; P = .11). The live birth rate was 81.3% for the RFA group and 86.7% in the BCO group (IRR, 0.93; 95% CI, 0.80-1.09; P = .41). BCO had higher neonatal death rates (8.1%) vs RFA (4.5%; IRR, 0.56; 95% CI, 0.30-1.04; P = .07). Overall survival was 76.8% for RFA and 79.1% for BCO (IRR, 0.97; 95% CI, 0.82-1.14; P = .72); however, none of these differences were statistically significant. Preterm premature rupture of membranes occurred in 17.7% of RFA cases and 28.2% of the BCO cases (IRR, 0.63; 95% CI, 0.43-0.91; P = .01). The mean median gestational age at delivery was 34.7 ± 1.7 weeks in the RFA group and 35.1 ± 1.6 weeks in the BCO group. Our data do not demonstrate clearly the superiority of 1 procedure over the other. The clinical situation and preference of the operator are important considerations. Rates of preterm delivery and preterm premature rupture of membranes remain substantial for both procedures.
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Affiliation(s)
- Kirsten Gaerty
- Mater Mothers' Hospital, South Brisbane, Queensland, Australia
| | - Ristan M Greer
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
| | - Sailesh Kumar
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia; Mater Mothers' Hospital, South Brisbane, Queensland, Australia.
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van Klink J, Koopman HM, Middeldorp JM, Klumper FJ, Rijken M, Oepkes D, Lopriore E. Long-term neurodevelopmental outcome after selective feticide in monochorionic pregnancies. BJOG 2015; 122:1517-24. [PMID: 26147116 DOI: 10.1111/1471-0528.13490] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess the incidence of and risk factors for adverse long-term neurodevelopmental outcome in complicated monochorionic pregnancies treated with selective feticide at our centre between 2000 and 2011. DESIGN Observational cohort study. SETTING National referral centre for fetal therapy (Leiden University Medical Centre, the Netherlands). POPULATION Neurodevelopmental outcome was assessed in 74 long-term survivors. METHODS Children, at least 2 years of age, underwent an assessment of neurologic, motor and cognitive development using standardised psychometric tests and the parents completed a behavioural questionnaire. MAIN OUTCOME MEASURES A composite outcome termed neurodevelopmental impairment including cerebral palsy (GMFCS II-V), cognitive and/or motor test score of <70, bilateral blindness or bilateral deafness requiring amplification. RESULTS A total of 131 monochorionic pregnancies were treated with selective feticide at the Leiden University Medical Centre. Overall survival rate was 88/131 (67%). Long-term outcome was assessed in 74/88 (84%). Neurodevelopmental impairment was detected in 5/74 [6.8%, 95% confidence interval (CI), 1.1-12.5] of survivors. Overall adverse outcome, including perinatal mortality or neurodevelopmental impairment was 48/131 (36.6%). In multivariate analysis, parental educational level was associated with cognitive test scores (regression coefficient B 3.9, 95% CI 1.8-6.0). Behavioural problems were reported in 10/69 (14.5%). CONCLUSIONS Adverse long-term outcome in survivor twins of complicated monochorionic pregnancies treated with selective feticide appears to be more prevalent than in the general population. Cognitive test scores were associated with parental educational level. TWEETABLE ABSTRACT Neurodevelopmental impairment after selective feticide was detected in 5/74 (6.8%, 95% CI 1.1-12.5) of survivors.
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Affiliation(s)
- Jmm van Klink
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - H M Koopman
- Clinical Psychology, Faculty of Social Sciences, Leiden University, Leiden, the Netherlands
| | - J M Middeldorp
- Division of Fetal Therapy, Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - F J Klumper
- Division of Fetal Therapy, Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - M Rijken
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - D Oepkes
- Division of Fetal Therapy, Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - E Lopriore
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, the Netherlands
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Kumar S, Paramasivam G, Zhang E, Jones B, Noori M, Prior T, Vasudeva A, Wimalasundera RC. Perinatal- and procedure-related outcomes following radiofrequency ablation in monochorionic pregnancy. Am J Obstet Gynecol 2014; 210:454.e1-6. [PMID: 24315860 DOI: 10.1016/j.ajog.2013.12.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Revised: 10/24/2013] [Accepted: 12/02/2013] [Indexed: 10/25/2022]
Abstract
OBJECTIVE We sought to assess the efficacy, complication rates, and outcomes for complex monochorionic pregnancies undergoing selective fetal reduction using radiofrequency ablation (RFA). STUDY DESIGN In this prospective observational study, 100 consecutive cases of selective fetal reduction using RFA were analyzed. All cases were managed at the Centre for Fetal Care at Queen Charlotte's and Chelsea Hospital in London. Indications for offering RFA, details of the procedure, and pregnancy outcomes were collected and analyzed. RESULTS The main indications for RFA were discordant fetal anomaly and twin-twin transfusion syndrome. Overall live birth rate was 78% and the median gestation at delivery was 35.15 weeks. Delivery <32 weeks' gestation occurred in 17.9% of cases. Postprocedure abnormal antenatal magnetic resonance imaging occurred in 3% of cases. There was no statistical difference in outcomes with regard to gestation when the procedure was performed or the indication for the RFA. CONCLUSION RFA appears to be a reasonable option for selective fetal reduction in complex monochorionic pregnancies with an overall survival rate of 78%.
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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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27
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Selective reduction in multiple gestations. Best Pract Res Clin Obstet Gynaecol 2014; 28:239-47. [DOI: 10.1016/j.bpobgyn.2013.12.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 11/13/2013] [Accepted: 12/10/2013] [Indexed: 11/23/2022]
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28
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Nobili E, Paramasivam G, Kumar S. Outcome following selective fetal reduction in monochorionic and dichorionic twin pregnancies discordant for structural, chromosomal and genetic disorders. Aust N Z J Obstet Gynaecol 2013; 53:114-8. [PMID: 23577786 DOI: 10.1111/ajo.12071] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 01/30/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND To investigate the indications for offering selective fetal reduction in monochorionic (MC) and dichorionic (DC) twins and to correlate obstetric outcome with the antenatal procedure. METHODS All cases of MC and DC twins discordant for structural anomalies and for chromosomal/genetic abnormalities were included. Selective reductions performed for twin-to-twin transfusion syndrome or growth restriction were excluded. For DC twins, feticide was achieved using intracardiac injection of potassium chloride (KCl). For MC twins, bipolar cord occlusion (BCO), interstitial laser or radiofrequency ablation (RFA) was used. RESULTS There were 121 twin pregnancies discordant for structural and chromosomal abnormalities. Only 88 (56 were MC twins and 32 were DC twins) had selective reduction. For both MC and DC twins, the leading indication for selective reduction was structural anomalies with CNS malformations the most common. For all MC fetal reduction techniques, the overall pregnancy loss rate (<24 weeks) was 8.9% with RFA having the lowest procedure loss rate (7.7%). The preterm delivery rate was lowest with reduction in DC pregnancies. The live birth rates for MC twins were >87% and 100% for DC twins. CONCLUSIONS Selective reduction in MC pregnancies carries an increased procedure-related and preterm delivery rate compared with DC pregnancies. The main indication for selective reduction was structural malformations, with a predominance of CNS anomalies.
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Affiliation(s)
- Elena Nobili
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK
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29
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Baud D, Windrim R, Kachura JR, Jefferies A, Pantazi S, Shah P, Langer JC, Forsey J, Chaturvedi RR, Jaeggi E, Keating S, Chiu P, Ryan G. Minimally invasive fetal therapy for hydropic lung masses: three different approaches and review of the literature. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 42:440-448. [PMID: 23712922 DOI: 10.1002/uog.12515] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2013] [Revised: 05/13/2013] [Accepted: 05/14/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To report three different antenatal therapeutic approaches for fetal lung masses associated with hydrops. METHODS Three prospectively followed cases are described, and all 30 previously published minimally invasive cases of fetal therapy for hydropic lung masses are reviewed. RESULTS Three hydropic fetuses with large intrathoracic lung masses presented at 17, 25 and 21 weeks of gestation, respectively. An aortic feeding vessel was identified in each case and thus a bronchopulmonary sequestration (BPS) was suspected. Under ultrasound guidance, the feeding vessel was successfully occluded with interstitial laser (Case 1), radiofrequency ablation (RFA) (Case 2) and thrombogenic coil embolization (Case 3). Complete (Cases 1 and 2) or partial (Case 3) resolution of the lung mass and hydrops was observed. A healthy infant was born at term after laser therapy (Case 1), and the involved lung lobe was resected on day 2 of postnatal life. In Case 2, hydrops resolved completely following RFA, but an iatrogenic congenital diaphragmatic hernia and abdominal wall defect became apparent 4 weeks later. The neonate died from sepsis following spontaneous preterm labor at 33 weeks. In Case 3, despite technical success in complete vascular occlusion with coils, a stillbirth ensued 2 days after embolization. CONCLUSIONS The prognosis of large microcystic or echogenic fetal chest masses associated with hydrops is dismal. This has prompted attempts at treatment by open fetal surgery, with mixed results, high risk of premature labor and consequences for future pregnancies. We have demonstrated the possibility of improved outcome following ultrasound-guided laser ablation of the systemic arterial supply. Despite technical success, RFA and coil embolization led to procedure-related complications and need further evaluation.
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Affiliation(s)
- D Baud
- Fetal Medicine Unit, Mount Sinai Hospital, Toronto, ON, Canada
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30
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van den Bos EM, van Klink JMM, Middeldorp JM, Klumper FJ, Oepkes D, Lopriore E. Perinatal outcome after selective feticide in monochorionic twin pregnancies. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 41:653-658. [PMID: 23335029 DOI: 10.1002/uog.12408] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 11/23/2012] [Accepted: 12/06/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To evaluate the incidence and risk factors of adverse perinatal outcome in complicated monochorionic twin pregnancies treated with selective feticide. METHODS This was a retrospective analysis of prospectively collected data from a consecutive, national cohort. All monochorionic twin pregnancies treated with selective feticide at Leiden University Medical Center between June 2000 and November 2011 were included. Obstetric and neonatal data were recorded. The primary outcome measure was adverse perinatal outcome, including fetal or neonatal demise or severe neonatal morbidity. RESULTS Data on perinatal outcome were obtained in all cases (n = 131). Overall perinatal survival rate was 67.2% (88/131). Median gestational age at delivery was 34 (interquartile range, 23-38) weeks. Neonatal mortality and morbidity rate in liveborn children was 4.3% (4/92) and 12.0 % (11/92), respectively. Severe cerebral injury was detected in three children. The overall incidence of adverse perinatal outcome was 41.2% (54/131). Median gestational age at occurrence of preterm prelabor rupture of membranes (PPROM) was 19.0 weeks and 32.0 weeks in cases with and without adverse perinatal outcome, respectively (P = 0.017). Liveborn children with adverse perinatal outcome were born at a lower median gestational age (29.0 weeks) than were children without adverse perinatal outcome (38.0 weeks) (P < 0.001). CONCLUSIONS The risk of adverse perinatal outcome after selective feticide is high and associated with low gestational age at occurrence of PPROM and low gestational age at delivery. Long-term follow-up to assess neurodevelopmental outcome in survivors is required.
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Affiliation(s)
- E M van den Bos
- Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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31
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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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Cabassa P, Fichera A, Prefumo F, Taddei F, Gandolfi S, Maroldi R, Frusca T. The use of radiofrequency in the treatment of twin reversed arterial perfusion sequence: a case series and review of the literature. Eur J Obstet Gynecol Reprod Biol 2013; 166:127-32. [DOI: 10.1016/j.ejogrb.2012.10.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Revised: 07/29/2012] [Accepted: 10/05/2012] [Indexed: 10/27/2022]
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33
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Delabaere A, Favre N, Velemir L, Bentaoui S, Coste K, Laurichesse-Demas H, Lemery D, Gallot D. [Pediatric outcome after selective feticide for 30 complicated monochorionic twin pregnancies]. ACTA ACUST UNITED AC 2013; 41:85-9. [PMID: 23369677 DOI: 10.1016/j.gyobfe.2012.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 12/21/2012] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To describe perinatal and pediatric outcome after selective feticide for complicated monochorionic twin pregnancy. PATIENTS AND METHODS We reviewed all consecutive cases of umbilical cord occlusion performed for complicated monochorionic twin pregnancy over a 16-year period. Pediatric follow-up was based on medical records and updated by phone calls to the parents. RESULTS Thirty procedures were performed. Indications were: twin-to-twin transfusion syndrome (TTTS) progressing despite serial amniodrainage (n=12) ; twin reversed arterial perfusion (n=9) ; selective growth restriction (n=5) ; severe discordant structural anomalies (n=4). Mean gestational age at procedure was 21.8±3.1gestational weeks (GW) and 31.8±4.8 GW at birth. Overall survival rate was 87%, i.e. 83%, 100%, 60% and 100% for each indication, respectively. Mean pediatric follow-up was 5years (range: 6months to 15years). Medical charts and parents declared normal development in 88% of surviving children, i.e. 67%, 100%, 100%, and 100% for each indication. Cross-comparison between the four groups revealed that in the TTTS group, gestational age at procedure was more advanced (P=0.01) while delivery was slightly earlier (P=0.1), and pediatric development was poorer (P=0.02). DISCUSSION AND CONCLUSION Pediatric outcome after selective feticide appeared to be poorer for TTTS progressing despite serial amniodrainage than for other indications.
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Affiliation(s)
- A Delabaere
- Pôle GOHR, unité de médecine fœtale, CHU d'Estaing, 1, place Lucie-Aubrac, 63003 Clermont-Ferrand cedex 1, France
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34
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Lu J, Ting YH, Law KM, Lau TK, Leung TY. Radiofrequency Ablation for Selective Reduction in Complicated Monochorionic Multiple Pregnancies. Fetal Diagn Ther 2013; 34:211-6. [DOI: 10.1159/000355406] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 08/30/2013] [Indexed: 11/19/2022]
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35
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Bebbington MW, Danzer E, Moldenhauer J, Khalek N, Johnson MP. Radiofrequency ablation vs bipolar umbilical cord coagulation in the management of complicated monochorionic pregnancies. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 40:319-324. [PMID: 22302774 DOI: 10.1002/uog.11122] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE The application of radiofrequency ablation (RFA) termination procedures to complicated cases involving monochorionic twins offers the potential of a less invasive option when compared to endoscopic techniques. The purpose of this study was to compare outcomes between these two techniques. METHODS A retrospective review was undertaken of all cases of complicated monochorionic twin gestations treated at the Children's Hospital of Philadelphia from July 1996 to December 2010. Cases were identified from the fetal treatment database and data extracted in a uniform fashion from the patients' charts. RESULTS A total of 149 cases were identified with procedures performed on 146. Indications for selective termination of one fetus were twin reversed arterial perfusion sequence in 53, severe twin-to-twin transfusion syndrome in 43, discordance for fetal anomalies in 26 and selective intrauterine growth restriction in 24. Eighty-eight cases were managed with bipolar cord coagulation (BCC) and 58 with RFA. The procedures in all cases were technically successful in achieving selective termination. The mean gestational age at the time of the procedure was 20.9 ± 2.7 weeks in the BCC group vs 20.2 ± 2.2 weeks in the RFA group (P = 0.1). The median gestational age at delivery was 34.7 (interquartile range (IQR), 29.2-38.6) weeks for the BCC group vs 33.0 (IQR, 23.4-38.9) weeks in the RFA group (P = 0.073). Mean birth weight did not differ between the two groups. The procedure-to-delivery time was 87.1 ± 42.1 days for the BCC group vs 73.8 ± 47.2 days for the RFA group (P = 0.1). Overall survival was 85.2% in the BCC group vs 70.7% in the RFA group (P = 0.014). This was attributed primarily to a survival rate of 10.5% in the RFA group compared with 31.6% in the BCC group for cases where delivery occurred before 28 weeks' gestation (P = 0.01). Premature rupture of the membranes occurred in 27.3% in the BCC group vs 13.7% in the RFA group (P = 0.05). Preterm labor was more common in the BCC group than in the RFA group (22.4 vs 7%, respectively; P = 0.009). CONCLUSION Despite the smaller caliber of the instrument, RFA is not associated with a decrease in the overall complication rate for selective termination procedures. The technique used for selective termination should still be determined by technical considerations but patients should be informed of the survival rate associated with each technique.
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Affiliation(s)
- M W Bebbington
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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36
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Long-term neurodevelopmental outcome in monochorionic twins after fetal therapy. Early Hum Dev 2011; 87:601-6. [PMID: 21831543 DOI: 10.1016/j.earlhumdev.2011.07.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2011] [Accepted: 07/05/2011] [Indexed: 11/24/2022]
Abstract
Monochorionic (MC) twins are at risk for several disorders, including twin-twin transfusion syndrome (TTTS), Twin Reverse Arterial Perfusion (TRAP) and selective intrauterine growth restriction (sIUGR). Several fetal interventions, such as serial amnioreduction (AR), fetoscopic laser coagulation of placental anastomoses (FLC) and selective feticide have lead to improved perinatal morbidity and mortality rates. Nevertheless, the rate of cerebral lesions in MC twins after fetal therapy appears to be high. Follow-up studies show a high incidence of cerebral palsy (CP) and neurodevelopmental impairment (NDI). We performed a systematic review on the long-term neurodevelopmental outcome in MC twins with TTTS following AR and FLC and MC twins following selective feticide of the co-twin due to TTTS, TRAP, sIUGR and congenital anomalies.
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Sepulveda W, Wong AE, Sandoval R, Aiello H, Otaño L. Monoamniotic twin pregnancy discordant for lethal open cranial defect: management dilemmas. Prenat Diagn 2011; 31:578-82. [DOI: 10.1002/pd.2751] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Revised: 02/16/2011] [Accepted: 02/26/2011] [Indexed: 11/12/2022]
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38
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Wimalasundera RC. Selective reduction and termination of multiple pregnancies. Semin Fetal Neonatal Med 2010; 15:327-35. [PMID: 20863776 DOI: 10.1016/j.siny.2010.08.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The substantial increase in high order multiple pregnancies in the last two decades as a result of assisted reproductive techniques has necessitated the development of multifetal pregnancy reduction as a management tool to decrease fetal number and improve perinatal survival. The evidence in favour of reduction in pregnancies with more than four fetuses to twins is undisputed. Despite the recent improvements in expectant management of triplets with reasonable perinatal outcomes, the evidence suggests that reduction to twins significantly reduces the risk of preterm delivery without an increase in miscarriage rates. Recent advances in vascular-occlusive techniques have allowed the possibility of selective termination in monochorionic pregnancies in the presence of discordant anomalies or indeed multifetal reduction in non-trichorionic triplets, with radiofrequency ablation and cord occlusion appearing to be the most successful. However, the techniques vary in complexity and complication rates, which increase with gestation. Hence the need to refer these pregnancies early to specialist centres.
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Affiliation(s)
- R C Wimalasundera
- Centre for Fetal Care, Queen Charlotte's & Chelsea Hospital, Imperial College Healthcare Trust, Du Cane Road, London W12 0HS, UK.
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39
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Paramasivam G, Wimalasundera R, Wiechec M, Zhang E, Saeed F, Kumar S. Radiofrequency ablation for selective reduction in complex monochorionic pregnancies. BJOG 2010; 117:1294-8. [PMID: 20722644 DOI: 10.1111/j.1471-0528.2010.02624.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Monochorionic pregnancies present unique challenges for selective fetal reduction, as vaso-occlusive procedures are required to ablate blood flow, usually in the umbilical cord, to achieve asystole in the selected fetus. We describe a case series of 35 monochorionic pregnancies (27 twins and eight triplets) undergoing selective fetal reduction using radiofrequency ablation. All procedures were performed under local anaesthesia. The procedure was technically successful in all cases. The live born rate was 88.6%. One (2.9%) woman miscarried within 2 weeks of the procedure, and two (5.7%) babies were stillborn. The median gestation at delivery was 36 weeks of gestation (range 24-41 weeks). There were no maternal complications. The median gestational age at procedure was 17 + 3 weeks (range from 12 + 5 to 27 + 4 weeks). All women had antenatal magnetic resonance imaging (MRI) post procedure. There were two (5.7%) cases of abnormal brain imaging. Our experience suggests that radiofrequency ablation is a safe and effective procedure for fetal reduction in complicated monochorionic pregnancies.
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Affiliation(s)
- G Paramasivam
- Centre for Fetal and Maternal Medicine, Queen Charlottes and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
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40
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Deprest JA, Flake AW, Gratacos E, Ville Y, Hecher K, Nicolaides K, Johnson MP, Luks FI, Adzick NS, Harrison MR. The making of fetal surgery. Prenat Diagn 2010; 30:653-67. [PMID: 20572114 DOI: 10.1002/pd.2571] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Fetal diagnosis prompts the question for fetal therapy in highly selected cases. Some conditions are suitable for in utero surgical intervention. This paper reviews historically important steps in the development of fetal surgery. The first invasive fetal intervention in 1963 was an intra-uterine blood transfusion. It took another 20 years to understand the pathophysiology of other candidate fetal conditions and to develop safe anaesthetic and surgical techniques before the team at the University of California at San Francisco performed its first urinary diversion through hysterotomy. This procedure would be abandoned as renal and pulmonary function could be just as effectively salvaged by ultrasound-guided insertion of a bladder shunt. Fetoscopy is another method for direct access to the feto-placental unit. It was historically used for fetal visualisation to guide biopsies or for vascular access but was also abandoned following the introduction of high-resolution ultrasound. Miniaturisation revived fetoscopy in the 1990 s, since when it has been successfully used to operate on the placenta and umbilical cord. Today, it is also used in fetuses with congenital diaphragmatic hernia (CDH), in whom lung growth is triggered by percutaneous tracheal occlusion. It can also be used to diagnose and treat urinary obstruction. Many fetal interventions remain investigational but for a number of conditions randomised trials have established the role of in utero surgery, making fetal surgery a clinical reality in a number of fetal therapy programmes. The safety of fetal surgery is such that even non-lethal conditions, such as myelomeningocoele repair, are at this moment considered a potential indication. This, as well as fetal intervention for CDH, is currently being investigated in randomised trials.
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Affiliation(s)
- Jan A Deprest
- Division Woman and Child, University Hospitals KU Leuven, Leuven, Belgium.
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41
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Roman A, Papanna R, Johnson A, Hassan SS, Moldenhauer J, Molina S, Moise KJ. Selective reduction in complicated monochorionic pregnancies: radiofrequency ablation vs. bipolar cord coagulation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2010; 36:37-41. [PMID: 20104533 DOI: 10.1002/uog.7567] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To compare radiofrequency ablation (RFA) and bipolar cord coagulation (BPC) methods for selective fetal reduction in the treatment of complicated monochorionic (MC) multifetal gestations. METHODS This was a retrospective review of patients who underwent selective reduction by RFA and BPC. Computer-generated random sampling was performed to match patients who had undergone BPC with patients who had undergone RFA, in a 2 : 1 ratio, controlling for gestational age and indication. The primary outcome was fetal survival. RESULTS Twenty patients in the RFA group were matched with 40 patients in the BPC group. Fewer additional intra-operative procedures were performed in the RFA group compared with the BPC group: amnioinfusion, 10% vs. 75%, respectively (P < 0.01); and amnioreduction, 5% vs. 40%, respectively (P = 0.004). The overall survival rates were 87.5% in the RFA group and 88% in the BPC group (P = 0.94). Median gestational age at delivery was 36 (range, 26-41) weeks in the RFA group and 39 (range, 19-40) weeks in the BPC group (P = 0.59). Preterm delivery (at < 28, < 32 or < 37 weeks), weeks gained after the procedure and birth weight at delivery were also similar. Although the preterm premature rupture of membranes (PPROM) rate was higher in the BPC group (22.5%) compared with the RFA group (5%), the difference was not statistically significant (P = 0.09). CONCLUSIONS Overall fetal survival rate following selective reduction in complicated MC pregnancies is similar whether reduction is performed by RFA or BPC. Fewer additional intraoperative procedures are required for RFA than for BPC. The possibility that RFA is associated with a lower rate of postoperative PPROM than is BPC will have to be confirmed in larger series.
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Affiliation(s)
- A Roman
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine, USA
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Napolitano R, Thilaganathan B. Late termination of pregnancy and foetal reduction for foetal anomaly. Best Pract Res Clin Obstet Gynaecol 2010; 24:529-37. [PMID: 20350838 DOI: 10.1016/j.bpobgyn.2010.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Accepted: 02/04/2010] [Indexed: 11/25/2022]
Abstract
Late termination of pregnancy is a relatively rare procedure accounting for approximately 1% of all registered terminations in England and Wales; however, with improving detection rates for foetal anomalies, this number is increasing. Surgical dilation and evacuation (D&E) appears to be a safe and cost-effective procedure as long as the clinical expertise exists to provide this service. Medical termination appears equally safe and is best undertaken with the combined use of mifepristone and misoprostol. Foeticide, when required, should be performed from 22 weeks' gestation using strong KCl administered either by cardiocentesis or by cordocentesis. All women should be offered a post-mortem and any other appropriate investigation to allow accurate counselling regarding future pregnancies. The issue of late selective foetal reduction for foetal abnormality is complicated by the need to balance the risks to the healthy co-twin of expectant management versus selective termination.
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Beck V, Pexsters A, Gucciardo L, van Mieghem T, Sandaite I, Rusconi S, DeKoninck P, Srisupundit K, Kagan KO, Deprest J. The use of endoscopy in fetal medicine. ACTA ACUST UNITED AC 2010. [DOI: 10.1007/s10397-010-0565-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Deprest JA, Devlieger R, Srisupundit K, Beck V, Sandaite I, Rusconi S, Claus F, Naulaers G, Van de Velde M, Brady P, Devriendt K, Vermeesch J, Toelen J, Carlon M, Debyser Z, De Catte L, Lewi L. Fetal surgery is a clinical reality. Semin Fetal Neonatal Med 2010; 15:58-67. [PMID: 19913467 DOI: 10.1016/j.siny.2009.10.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
An increasing number of fetal anomalies are being diagnosed prior to birth, some of them amenable to fetal surgical intervention. We discuss the current clinical status and recent advances in endoscopic and open surgical interventions. In Europe, fetoscopic interventions are widely embraced, whereas the uptake of open fetal surgery is much less. The indications for each access modality are different, hence they cannot substitute each other. Although the stage of technical experimentation is over, most interventions remain investigational. Today there is level I evidence that fetoscopic laser surgery for twin-to-twin transfusion syndrome is the preferred therapy, but this operation actually takes place on the placenta. In terms of surgery on the fetus, an increasingly frequent indication is severe congenital diaphragmatic hernia as well as myelomeningocele. Overall maternal safety is high, but rupture of the membranes and preterm delivery remain a problem. The increasing application of fetal surgery and its mediagenicity has triggered the interest to embark on fetal surgical therapy, although the complexity as well as the overall rare indications are a limitation to sufficient experience on an individual basis. We plead for increased exchange between high volume units and collaborative studies; there may also be a case for self-regulation. Inclusion of patients into trials whenever possible should be encouraged rather than building up casuistic experience.
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Affiliation(s)
- Jan A Deprest
- Division Woman and Child, University Hospital Gasthuisberg, Leuven, Belgium.
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Current world literature. Curr Opin Ophthalmol 2009; 20:333-41. [PMID: 19535964 DOI: 10.1097/icu.0b013e32832e478f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chavira ER, Khan A, Korst LM, Miller D, Goodwin TM, Chmait RH. Are patients with twin-twin transfusion syndrome and a very short cervix candidates for laser surgery? JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2009; 28:633-639. [PMID: 19389902 DOI: 10.7863/jum.2009.28.5.633] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVES The purpose of this study was to determine the relationship between cervical length (CL) and perinatal outcomes in cases of twin-twin transfusion syndrome (TTTS) treated with laser surgery and to assess whether patients with a very short cervix (0.5-1.9 cm) are appropriate candidates for laser surgery. METHODS All women who underwent laser surgery for TTTS from March 2006 to April 2008 at the study institution were evaluated consecutively. Patients were grouped according to pre-operative CL: greater than 2.5, 2 to 2.5, and 0.5 to 1.9 cm. The gestational age at delivery, latency from laser surgery to delivery, and 30-day neonatal survival were documented prospectively and compared among these groups. RESULTS The 99 women in the study population were grouped by CL: greater than 2.5 cm (n = 76), 2 to 2.5 cm (n = 13), and 0.5 to 1.9 cm (n = 10). For these groups, the median gestational ages at delivery were 34, 32.29, and 31.86 weeks, respectively (P = .411). The median latencies from laser surgery to delivery were 12.79, 11, and 11.07 weeks (P = .424). The frequency rates of at least 1 surviving twin were 69 of 76 (91%), 13 of 13 (100%), and 8 of 10 (80%) (P = .254). Finally, dual survivors were observed in 54 of 76 (71%), 12 of 13 (92%), and 5 of 10 (50%) (P = .08). CONCLUSIONS In cases of TTTS complicated by a very short cervix (0.5-1.9 cm), treatment with laser surgery resulted in perinatal outcomes that were sufficiently favorable to justify the surgery, suggesting that these patients should not be excluded from undergoing laser surgery for TTTS.
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Affiliation(s)
- Emiliano R Chavira
- Division of Maternal-Fetal Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA 90027, USA
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Rossi AC, D'Addario V. Umbilical cord occlusion for selective feticide in complicated monochorionic twins: a systematic review of literature. Am J Obstet Gynecol 2009; 200:123-9. [PMID: 19185099 DOI: 10.1016/j.ajog.2008.08.039] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Revised: 08/09/2008] [Accepted: 08/19/2008] [Indexed: 11/19/2022]
Abstract
The aim of this study was to review literature concerning selective feticide (SF) in monochorionic pregnancies complicated with twin-twin transfusion syndrome, twin reversed arterial perfusion, severe malformation, and discordant growth. The remaining twins' outcomes were stratified for indication and surgical technique. Three hundred forty-five cases of SF were reviewed. Premature rupture of membranes was described in all the procedures and complicated 76/345 (22%) pregnancies within 4 postoperative weeks (59%) or later (41%; P = .52). Fetal demise accounted for 51/345 (15%), more frequently within 2 postoperative weeks (79%) than thereafter (21%; P = .004; odds ratio [OR], 6.12; 95% confidence interval [CI], 1.81-20.70). Improved survival rate was achieved in surgeries after 18 weeks (89%) than earlier (69%; P = .02; OR, 0.28; 95% CI, 0.10-0.80) without differences for indication. Survivors were 86% after radiofrequency ablation, 82% after bipolar cord coagulation, 72% after laser cord coagulation, 70% after cord ligation. In spite of favorable outcomes, the optimal surgical approach remains undetermined.
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Affiliation(s)
- A Cristina Rossi
- IV Clinic of Obstetrics and Gynecology, University of Bari, Bari, Italy.
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Klaritsch P, Albert K, Van Mieghem T, Gucciardo L, Done’ E, Bynens B, Deprest J. Instrumental requirements for minimal invasive fetal surgery. BJOG 2008; 116:188-97. [DOI: 10.1111/j.1471-0528.2008.02021.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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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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